Central Nervous System and Renal Vasculitis Associated With Primary Varicella Infection in a Child

Abstract

ABSTRACT. A 7-year-old girl with primary varicella presented with encephalopathy and focal neurologic deficits 10 days after her first skin lesions appeared. She was discovered to have bilateral wedge-shaped renal infarctions, and ischemic lesions in the conus medullaris, cerebral cortex, and deep gray matter consistent with a medium and large vessel arteritis on magnetic resonance imaging. This complication has never before been reported in an immunocompetent child with primary varicella infection, and it represents a rare but serious complication of childhood chickenpox. Pediatrics 2001;107(1). URL: http://www.pediatrics.org/cgi/content/full/107/1/e9; varicella, child, vasculitis, cerebral arteritis, renal arteritis.ABBREVIATIONS. VZV, varicella-zoster virus; MRI, magnetic resonance imaging; CSF, cerebrospinal fluid; IgG, immunoglobulin G; IgM, immunoglobulin M; PCR, polymerase chain reaction. V aricella-zoster virus (VZV) may produce a wide spectrum of neurologic diseases in children, including postinfectious encephalitis, 1 Reye's syndrome, 2 acute cerebellar ataxia, 3 and herpes zoster ophthalmicus with delayed contralateral hemiparesis. 4,5 VZV recurrence in the trigeminal or cervical distribution may be associated with a vasculopathy affecting both large and small arteries, typically producing stroke or stroke-like symptoms weeks to months after eruption of the vesicles. 6 This vasculopathy is more common in immunocompromised patients. 7 We describe a VZV arteritis in an immunocompetent child occurring 10 days after the onset of the initial rash of primary varicella, producing ischemic vascular lesions in the brain, spinal cord, and kidneys. CASE REPORTA 7-year-old girl in good health presented with confusion, lethargy, and right-sided weakness for ϳ2 hours on the day of admission. She had healing skin lesions consistent with a recent history of primary varicella 10 days before presentation. Her initial rash resolved after a few days with no new lesions, and 7 days before admission she had returned to school. Four days before admission, she complained of headache and eye pain on exposure to light and developed a low-grade fever with occasional vomiting. Over the next 48 hours, she became difficult to awaken. She could not stand without support and was unsure of what to do with a popsicle offered to her. The act of swallowing would induce projectile vomiting. She began to repeat the words "I am" in response to all questions. On the day of admission, she could not be aroused and was brought to the hospital.In the emergency department, her temperature was 98.6°F with pulse, 74 beats per minute; respiratory rate, 16 breaths per minute; and blood pressure, 112/70 mm Hg. Numerous healing cutaneous lesions consistent with recent varicella infection were present. No open vesicles were noted on her skin, ears, or mouth; hepatosplenomegaly or lymphadenopathy was not present. She was awake but minimally responsive to forceful pinching. Pupils were equal, round, and reactive with a right gaze preference. A left facia...

The value of detecting anti-VZV IgG antibody in CSF to diagnose VZV vasculopathy

“…[13][14][15][16][17][18][19] In five of seven of these cases, anti-VZV IgG antibody, but not VZV DNA, was found in CSF. Although those reports support our finding that detection of anti-VZV IgG antibody is superior to the detection of VZV DNA to diagnose VZV vasculopathy, the cases were not included in our analysis because of possible variability in PCR and EIA techniques among different laboratories.…”

Ischemic Spinal Cord Infarction in Children Without Vertebral Fracture

“…Emboli formation can be iatrogenic: embolic material to the spinal cord vasculature is reported in a pediatric patient undergoing sclerotherapy of esophageal varices [56]. Thrombotic vasculitis and/or occlusive arachnoiditis was implicated in cord infarction of many children with central nervous system infections [53,[57][58][59][60][61][62][63][64][65][66][67][68][69]. Several thrombotic disorders have been reported in cases of spinal cord infarction [70][71][72][73][74][75].…”

“…4 Hypotension Cardiac arrest [29] 6 Cardiac tamponade [30] 1 Arteriovenous malformation Vascular steal [32] 1 Mechanism unknown [31] 5 Thrombotic disorders Prothrombin variant [70,71] 2 Protein S deficiency [75] 1 Primary antiphospholipid syndrome [72] 1 Systemic lupus erythematosis [17,77] 3 Infectious disease Bacterial meningitis [53,[57][58][59][60][61][62][63][64][65][66][67] 15 Amebic menigoencephalitis [69] 1 Viral encephalitis [68] 1 Cerebellar herniation Metabolic encephalopathy [50] 3 Minor trauma [41][42][43][44][45][46][47][48] 18 Fibrocartilaginous embolism [1][2][3][85][86][87][88][89] 10 Cancer Anterior spinal artery thrombosis [76] 1 Atlanto-axial instability Achondroplasia [22] 1 I-cell disease [20] 1 Iatrogenic Sclerotherapy of esophageal varices [56] 1 Prolonge...…”

Varicella-Zoster Infection with Encephalopathy, Pneumonia, and Renal Failure: A Case Report

“…[9][10][11] This complication can be mediated via a cytotoxic mechanism owing to tissue damage associated with immune cell responses. These complications tend to occur either toward the end of the disease or one to two weeks after its termination.…”

“…[2][3][4][5] However, multiple organ involvement as a complication of VZ infection in adults is rare. [6][7][8][9][10][11] This study reports a case of disseminated VZ infection successfully treated with acyclovir.…”