Painful legs and moving toes syndrome associated with herpes zoster myelitis

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Abstract

A 75-year-old woman developed painful legs and moving toes syndrome (PLMT) 16 months after the onset of herpes zoster (HZ) myelitis. Although the scattered extensive lesions due to HZ myelitis were observed to be eccentric near the posterior horn on MRI, these changes had disappeared upon the development of PLMT. Combined median and tibial nerve somatosensory evoked potentials demonstrated abnormal findings only in the tibial nerve stimuli, suggesting that a severe alteration occurred in the somatosensory fibers coming selectively from the lower legs. These findings suggest plasticity in the ascending somatosensory pathway including the posterior horn cells, probably involving the interneuron networks, for the lower legs may underlie the development of PLMT associated with HZ myelitis.

Introduction

Painful legs and moving toes syndrome (PLMT) is a rare condition characterized by distressing pain in the lower legs and peculiar involuntary movements of the toes [1], [2]. Although herpes zoster (HZ) is one of the etiologies for PLMT that has been previously reported [1], [2], whether central nervous system (CNS) lesions due to the virus traveling centripetally along the posterior root play a definite role in the development of PLMT is unknown. To our knowledge, this is the first description of PLMT associated with HZ myelitis with spreading multiple lesions in the spinal cord.

Section snippets

Case report

A previously healthy 75-year-old woman developed a vesicular rash on the right thigh in December 1999. In early January of 2000, her legs began tingling. In the next few weeks, the tingling extended to her trunk. At the end of February 2000, a neurological examination revealed decreased vibratory sensation in the right hand and leg and hypoesthesia in the right arm and both legs. Deep tendon reflexes showed a depressed right patella reflex and absent ankle jerks. Both plantar responses were

Discussion

A diagnosis of HZ myelitis was made based on the close relationship between the skin rash and the onset of myelopathy, and on asymmetrical neurological findings that is one characteristic of HZ myelitis [5]. The MRI findings also supported the diagnosis of HZ myelitis for the following reasons: (1) the bottom lesion was at the level that corresponds to the dermatome distribution of the vesicular rash, and (2) the lesions were eccentric near the posterior horn, to which the HZ virus within the

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