Elsberg syndrome related to varicella zoster virus infection with painless skin lesions in an elderly woman with poorly controlled type 2 diabetes mellitus

Abstract

Patients with diabetes mellitus (DM) are at increased risk of infections, with the urinary tract being the most frequent infection site. Incomplete bladder emptying, frequent urination and abdominal distension are typical symptoms of urinary tract infections (UTIs). A 68-year-old female with a long history of poorly controlled type 2 DM (T2DM) visited our hospital complaining of urinary retention, which was initially diagnosed as cystitis by another doctor. The urologist at our hospital identified a skin rash extending from the left hip to her genital area. A dermatologist was consulted. She was clinically diagnosed with herpes zoster (HZ) involving the left sacral dermatome area. As Elsberg syndrome (ES) was suspected, a lumbar puncture was performed, revealing aseptic meningitis associated with varicella zoster virus (VZV) infection. Intravenous acyclovir with urinary catheterization in combination with methylprednisolone pulse therapy resulted in a good clinical course. HZ very uncommonly involves sacral dermatomes, but it can develop in patients with prolonged poorly controlled DM. Furthermore, early diagnosis can be difficult when patients have diabetic peripheral neuropathy, which may mask symptoms related to skin lesions. Because this disease is potentially severe, detailed examination is important for clinicians managing patients with DM who have complaints indicative of urinary tract disorders.

Meningitis retention syndrome caused by varicella zoster virus in a patient without a rash: a case report

“…MRS is a rare condition that presents with complications of aseptic meningitis and dysuria [2]. Furthermore, MRS due to VZV is rare [2,4,5,7,[10][11][12]. To the best of our knowledge, only one previous case of VZV meningitis without a rash that led to MRS has been reported [5].…”

Disseminated Herpes Zoster Infection with Urinary Retention and Incontinence

“…As a drug therapy, α-blockers such as urapidil [15], bethanechol chloride [15,16], and distigmine bromide [15] are used for the treatment of a neurogenic bladder. There are reports stating that the early use of steroidal drugs can also be effective for treating meningitis [17][18][19] and urinary retention [18]. It is important to consider these drugs depending on the case; however, there is no evidence-based drug therapy for urinary retention.…”

Elsberg syndrome in HSV-2 infection

“…ES typically presents as cauda equina syndrome (CES), with symptoms of sensory impairment, lower extremity weakness, saddle anesthesia, and urinary and/or bowel incontinence [7] , [9] . It is usually associated with infectious causes such as SARS-CoV-2 [1] , West Nile Virus [5] , Varicella Zoster Virus (VZV) [2] , [6] , and Herpes Simplex Virus Type 2 (HSV-2), with HSV-2 being the predominate causative pathogen [7] . HSV-2 is dormant in 40% of sacral dorsal root ganglia; when reactivated, virus can spread axonally into the spinal cord [4] .…”

“…Immunocompromised patients such a those with malignancy, HIV, or history of organ transplants are at a greater risk for Herpes Zoster infections, which is a cause of infectious lumbosacral radiculitis and myelitis [3] . Additionally, ES related to VZV should be considered in the differential diagnosis of patients with prolonged poorly controlled T2DM [6] . Treatment with acyclovir, even in cases without a definitive viral cause, is considered beneficial in many cases [7] .…”

“…The use of Steroids in the treatment of ES is debated. Oral steroid tapers or short course high dose IV steroids can be used to help shorten the duration of symptoms [6] , [7] . Elsberg syndrome accounts for approximately 5–10% of cauda equina syndrome and myelitis [7] and up to 30% of patients have a recurrence of symptoms within the first year [4] .…”