Hemorrhagic demyelinating lesions and systemic thrombosis due to Varicella Zoster infection: a case report

Abstract

Introduction: The investigation of hemorrhagic demyelinating cerebral lesions is challenging with diverse etiologies. We report a case of varicella zoster virus (VZV) infection with prominent hemorrhagic demyelinating component and systemic thrombosis. Objectives: Describe a case of hemorrhagic demyelinating lesions and systemic thrombosis secondary to varicella zoster central nervous system infection. Case report: A 45-year-old man presented with a one-week history of left leg strength loss associated with pyramidal liberation on the left side. Brain MRI showed two expansive hemorrhagic lesions, in the frontoparietal lobe and in the cingulate gyrus region. There were T2/FLAIR hypersignal in the subcortical area of both cerebral hemispheres and in the cervical cord, suggestive of demyelination. His arterial magnetic resonance imaging with vessel wall imaging showed focal tapering on the pial branches of the middle cerebral artery, but his digital angiography showed no abnormalities. The lumbar puncture had 8 cells, (lymphocyte predominance), 52 proteins/ dL, and 53 mg/dL of glucose. In two days, he developed a left side hemiplegia associated with seizures and pulmonary thromboembolism, demanding lung mechanical thrombectomy and anticoagulation. He had a positive lupus anticoagulant and a positive VZV IgG in the cerebrospinal fluid associated with positive oligoclonal bands. He received intravenous acyclovir with complete resolution of the symptoms. Conclusion: The clinical manifestations of VZV infection are wide, and we should suspect of this infection in patients with central nervous system demyelinating lesions, even without other skin lesions.