Stroke and multiple peripheral thrombotic events in an adult with varicella

Abstract

Sirs, Varicella is typically a benign childhood disease caused by varicella zoster virus (VZV), though serious complications can arise [1,2]. Varicella has been commonly associated with stroke in children [3], but exceptional reports have described afflicted immunocompetent adults, repeatedly relating vasculitis with this condition [4][5][6][7][8].A 39-year-old right-handed male, smoker (10 cigarettes/day), developed varicella 2 weeks after his 4-year-old daughter showed the characteristic rash. Acute pain and pallor of the left lower limb and absent ipsilateral foot pulses suddenly emerged 1 week later, as well as left hemiplegia, left homonymous hemianopia and hemineglect. Emergent lower limb angiography ( Fig. 1a and b) showed one occlusive (left femoral artery) and two sub-occlusive thrombi (left common iliac and right femoral arteries); thromboembolectomy was carried out. Intravenous non-fractionated heparin, acyclovir and methylprednisolone (5-day course, followed by oral prednisone and tapering) were prescribed. Acyclovir and corticosteroids were employed because of suspected VZV-related vasculitis. Central retinal artery occlusion of the right eye, probably the first event according to the patient, was later perceived. Laboratory examinations revealed: increased leucocytes (16.87 · 10 9 /l), C-reactive protein (19.3 mg/l) and erythrocyte sedimentation rate (49 mm/h), low protein S (0.18 U/ml, normal range 0.60-1.40), positive anticardiolipin IgM and antibeta2-glycoprotein-I IgM (25.3 MPL and 45.5 SMU, respectively; normal <15), positive VZV-specific IgM and positive VDRL at 1:8 dilutions (TPHA negative). Other blood tests were normal, including folic acid, vitamin B12, homocysteine, thyroid function tests; microbial cultures; screening for HIV, HBV and HCV; immunological screening; other basic coagulation tests and inherited prothrombotic disorders screening. Cerebrospinal fluid examination disclosed 9 cells/ mm 3 , normal protein and glucose levels;negative VZV DNA, anti-VZV antibodies (IgM, IgG), VDRL, TPHA and cultures. Transesophageal echocardiography and ECG were normal. Carotid and transcranial ultrasound showed eccentric luminal stenosis (40%) of the proximal right internal carotid artery with hypoechoic material; on serial testing, gradual shrinkage (to 20% 20 days later) and distal progression were demonstratedfindings that cannot be attributed to an atherosclerotic plaque. Brain MRI (1.5 T) was conducted 1 week after admission, showing the lesions observed in Fig. 1c. On discharge the patient presented right eye blindness, left hemiparesis and hemianopia; 3 months later he walked autonomously using one crutch. All abnormal laboratory findings returned to normal and so remained. Warfarin was stopped 6 months later; his current medication consists of antiplatelet drug and statin.We believe that these data strongly suggest that the vascular events sustained by this patient were associated with VZV, and occurred in the setting of a transitory prothrombotic condition, which also finds support in the ...

The Short- and Long-Term Risk of Stroke after Herpes Zoster - A Nationwide Population-Based Cohort Study

“…[5], [6] This study also confirms the short-term effect described in previous case reports and reviews. [7], [8], [11] It expands on previous reports by providing a detailed analysis with respect to time since herpes zoster infection, including an analysis of the long-term risk following infection. The risk was increased by 127% during the first two weeks, 17% between two weeks and one year after herpes zoster, and 5% after one year.…”

“…The observed association may also be the result of a transient prothrombotic condition caused by the viral infection. [8], [19].…”

Increased Risk of Stroke After a Herpes Zoster Attack

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Update on Varicella Zoster Virus Vasculopathy

“…Massano et al [39] reported a case of multifocal VZV vasculopathy with peripheral thrombotic disease associated with transient hypercoagulation abnormalities. One week after varicella, a 39-year-old man developed central retinal artery occlusion, ischemic stroke with a small hemorrhage and proximal right middle cerebral artery occlusion, along with occlusive left femoral artery and two thrombi in the left common iliac and right femoral arteries.…”