Lau Arthur, Essien Eno-Obong, Tan Irene J
Rheumatology, Temple University Hospital, Philadelphia, USA.
Internal Medicine, Temple University Hospital, Philadelphia, USA.
Cureus. 2020 Mar 10;12(3):e7231. doi: 10.7759/cureus.7231.
Central nervous system (CNS) vasculopathy caused by varicella zoster virus (VZV) is a rare condition. Rarer still is the development of CNS vasculopathy in the absence of a typical zoster rash, a phenomenon known as zoster sine herpete. We report a case of a 34-year-old male with HIV, non-compliant with highly active antiretroviral therapy (HAART), who presented with left-sided temporal headaches and numbness without rash. The patient had a complicated one-month hospital stay when he was initially diagnosed with mycobacterium avium complex (MAC) tuberculosis infection and treated with isoniazid, rifabutin, ethambutol, and azithromycin. Additionally, he was thought to have immune reconstitution inflammatory syndrome (IRIS) and was given steroids. Unfortunately, he presented one day post-discharge with lethargy, aphasia, and dysphagia and was found to have acute/subacute infarcts affecting multiple areas of the brain. CT angiogram (CTA) of the brain showed evidence of multifocal areas of mild to moderate stenosis throughout the intracranial arterial circulation. The patient underwent conventional angiography, which showed segmental arterial constrictions with post-stenotic dilatation consistent with vasculitis. Cerebrospinal fluid (CSF) studies eventually returned positive for VZV by polymerase chain reaction (PCR), confirming a diagnosis of VZV-induced CNS vasculopathy, or more specifically, CNS vasculopathy due to zoster sine herpete. The patient was treated with high-dose steroids as well as IV acyclovir with improvement in his symptoms. He was discharged with advice for a close follow-up with the infectious disease (ID) department. Our case highlights the importance of maintaining a high index of suspicion for varicella infection masquerading as CNS vasculitis, particularly in the absence of classic blistering shingles rash. Early detection may prevent neurological sequelae of the infection, including stroke, dissection, or neuropathy.
由水痘带状疱疹病毒（VZV）引起的中枢神经系统（CNS）血管病变是一种罕见的病症。在没有典型带状疱疹皮疹的情况下发生CNS血管病变的情况更为罕见，这种现象被称为无疱疹性带状疱疹。我们报告一例34岁男性艾滋病患者，未坚持高效抗逆转录病毒治疗（HAART），出现左侧颞部头痛和麻木，无皮疹。该患者最初被诊断为鸟分枝杆菌复合群（MAC）结核感染，并接受异烟肼、利福布汀、乙胺丁醇和阿奇霉素治疗，住院一个月，病情复杂。此外，他被认为患有免疫重建炎症综合征（IRIS）并接受了类固醇治疗。不幸的是，他出院一天后出现嗜睡、失语和吞咽困难，发现有影响大脑多个区域的急性/亚急性梗死。脑部CT血管造影（CTA）显示颅内动脉循环中多处有轻度至中度狭窄的证据。患者接受了传统血管造影，显示节段性动脉狭窄伴狭窄后扩张，符合血管炎表现。脑脊液（CSF）研究最终通过聚合酶链反应（PCR）检测VZV呈阳性，确诊为VZV诱导的CNS血管病变，更具体地说是无疱疹性带状疱疹所致的CNS血管病变。患者接受了高剂量类固醇以及静脉注射阿昔洛韦治疗，症状有所改善。出院时建议他密切随访感染病（ID）科。我们的病例强调了对伪装成CNS血管炎的水痘感染保持高度怀疑的重要性，特别是在没有典型水疱性带状疱疹皮疹的情况下。早期发现可能预防感染的神经后遗症,包括中风、动脉夹层或神经病变。
