2009 Southern Regional Meeting Abstracts

Case Report: A treatment experienced HIV positive 49-year-old woman presented with headache, chills, photophobia, neck pain and a painful rash. Her past history was negative except for hepatitis C and HIV for which she was on Truvada and Lexiva. Physical examination was normal except for painful vesicular lesions on her face, neck, upper torso and extremities with a benign neurological exam. Initial lab work showed WBCs of 2,700, CD4 count 186, HIV viral load of 6,000 and serum chemistries within normal limits. An LP with CSF analysis showed 30 WBC with 81% lymphocytes, normal glucose, and elevated protein and was negative for Cryptococcal antigen, West Nile virus, Varicella-Zoster virus (VZV) and HSV. CXR and CT Head were normal. The patient soon developed acute onset of right lower extremity weakness with diminished reflexes at the knee and ankle. An MRI of the brain and spine showed a focal, mildly expansile lesion of the cord between T9-T11 suggestive of inflammation or tumor. CSF PCR for VZV later returned positive confirming the diagnosis. Intravenous acyclovir had been started empirically and was thus continued. The patient gradually showed improvement with almost complete resolution of her weakness.
Discussion: Herpes zoster can occur in any host but is often more pronounced in the elderly and immunocompromised. Various studies have demonstrated an incidence of Zoster as high as 30% in the HIV population as compared to the general population (10%). The most common manifestation is a vesicular rash in a dermatomal distribution, but several neurological complications can also be seen ranging from aseptic meningitis to rare cases of transverse myelitis (<0.5%) as seen in our patient. Treatment of Zoster related transverse myelitis is with acyclovir which provides gradual symptomatic improvement if started promptly. Clinical trials are also underway to examine the utility of the Zoster Vaccine in HIV patients to prevent such complications. In conclusion, early recognition and treatment of this uncommon complication of VZV reactivation is essential so that appropriate treatment can be initiated and severe neurologic damage averted, especially in the most vulnerable of populations: the immunocompromised.