Recurrent polymorphonuclear pleocytosis with increased red blood cells caused by varicella zoster virus infection of the central nervous system: Case report and review of the literature

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Abstract

We describe an immunocompetent 45-year-old woman who had four episodes of neurological disease (meningoencephalitis, multifocal vasculopathy, myelitis and inflammatory brain stem disease) produced by varicella zoster virus (VZV) over an 11-month period, all in the absence of rash. The cerebrospinal fluid (CSF) contained anti-VZV IgG antibody, but not VZV DNA throughout her illness, reaffirming the superiority of detection of anti-VZV IgG in CSF compared to VZV DNA in diagnosing VZV infection of the nervous system. Moreover, 3 of 7 CSF samples examined during the 11 months showed a VZV-induced pleocytosis consisting predominantly of polymorphonuclear cells (PMNs), and 4 of 7 samples also contained increased numbers of red blood cells (RBCs). Because increased PMNs and RBCs in CSF can also occur in patients with central and peripheral nervous system disease produced by cytomegalovirus (CMV), the differential diagnosis of chronic nervous system infection with increased PMNs and RBCs in CSF should include analyses for both VZV and CMV.

Introduction

The protean clinical manifestations of varicella zoster virus (VZV) infection of the central nervous system (CNS) include meningoencephalitis, multifocal vasculopathy and myelitis, all of which can occur without rash [1]. The cerebrospinal fluid (CSF) usually contains a mild pleocytosis, mostly mononuclear, although PMNs occasionally predominate. In addition, the CSF may contain increased red blood cells (RBCs). We describe a patient who developed multiple episodes of CNS disease in the absence of rash, serologically confirmed to be caused by VZV, with increased PMNs and RBCs in the CSF on multiple occasions.

Section snippets

Case report

In November 2008, a 45-year-old woman developed confusion, an expressive aphasia and a mild spastic paraparesis with left-sided hyperreflexia. Brain magnetic resonance imaging (MRI) revealed bilateral non-enhancing cortical and subcortical T2 hyperintensities (Fig. 1) as well as leptomeningeal enhancement. The CSF contained 26 white blood cells (WBCs), 100% mononuclear cells (MNCs), 387 RBCs, protein 140 mg%, and glucose 58 mg%. CSF IgG was 24.1 mg%, which constituted 17.2% of total CSF protein

Discussion

We describe an immunocompetent 45-year-old woman who had four episodes of neurological disease over an 11-month period, all in the absence of rash. The initial attack was characterized by an acute meningoencephalitis and multifocal vasculopathy. Seven months later, she developed chronic myelitis. Six weeks after the onset of myelitis, she developed recurrent multifocal vasculopathy and increasingly severe myelitis that rendered her paraplegic. Two months later, she developed inflammatory brain

Acknowledgements

This work was supported in part by the Public Health Service grants AG006127, and NS032623 and AG032958 from the National Institutes of Health. The authors thank Marina Hoffman for editorial review and Cathy Allen for manuscript preparation.

The findings and conclusions in this report are those of the authors and do not necessarily represent the view of the Centers for Disease Control and Prevention.

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