Abstract
Objectives Varicella Zoster Virus (VZV) can cause a spectrum of neurological presentations.
Methods Case report.
Results We describe the case of a 66 year old immunocompetent male who presented with a 2 day history diplopia and left sided ataxia on the background of a recent left facial VZV infection, presenting with vesicular rash and dysesthesia in the left trigeminal V2 and V3 distributions. Examination revealed a left internuclear ophthalmoplegia with skew deviation, left hemifacial numbness and tandem gait instability. CSF protein was elevated. Facial swab was VZV PCR positive. CT Angiogram revealed no intracranial stenosis suggestive of a vasculopathy. 1.5 T MRI Brain and Spine revealed high T2 signal in the dorso-lateral pons, medulla and adjacent upper cervical cord in the trigeminal nuclei. Smaller foci were also present in the left facial colliculus and in the right inferior cerebellar peduncle reflective of a rhombencephalomyelitis. Antiviral therapy was administered for 2 weeks. Follow up 3 T MRI at 5 weeks post discharge additionally revealed high T2 signal along the course of the left trigeminal nerve in the brainstem as well as high T2 signal and enhancement in the cisternal segment of the left trigeminal nerve. There was clinical improvement in all neurological symptoms over a 3 week period.
Conclusion This case demonstrates that VZV can result in a broad inflammatory process across the neuraxis and cause a rhombencephalomyelitis in immunocompetent adults. MR imaging can confirm brainstem involvement.
