SHM Converge Scientific Abstract ePoster Gallery-A Rash Decision: Varicella Zoster Reactivation With Lumbar Polyradiculitis

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This case report describes a 31-year-old man with rheumatoid arthritis receiving adalimumab, methotrexate, and prednisone who developed varicella zoster virus (VZV) reactivation presenting as lumbar polyradiculitis. He had a 3-day history of fatigue, severe asymmetric lower-extremity weakness, and a painful vesicular rash across multiple dermatomes of the left lower limb. Examination showed no myelopathy or meningismus.<br /><br />Because the presentation strongly suggested VZV radiculitis, intravenous acyclovir was started and his home immunomodulatory therapy was temporarily held. A lumbar puncture was not performed, since characteristic skin lesions were already present and cerebrospinal fluid testing was felt unnecessary. MRI of the whole spine showed no abnormal cord or nerve root enhancement. Vesicular fluid later tested positive for VZV DNA by RT-PCR, and serology was also positive.<br /><br />The patient improved rapidly: weakness improved within 48 hours and the rash gradually resolved. He did not receive corticosteroid pulses or varicella zoster immune globulin (VZIG), as these treatments remain controversial and may carry additional risks. The authors note that IV acyclovir alone can be sufficient even in immunocompromised patients.<br /><br />A key management question was when to safely restart immunosuppressive therapy. Based on limited evidence, adalimumab was restarted about 6 weeks later, after the lesions had healed and motor function returned to baseline. This was done without complications. By 3 months, the patient had returned to running several miles per day.<br /><br />The report emphasizes that lumbar puncture may not be required in classic cases with shingles-like skin findings, MRI may help exclude spinal cord involvement, IV acyclovir is an effective treatment, and immunomodulatory therapy can potentially be resumed once clinical recovery is complete.

Asset Subtitle

Carolyn Molina

Meta Tag

Author List Brock Polnaszek, Carolyn Molina, Erica Hardy, Hadeel Zainah, Mauricio F. Villamar, Vaughn M. Williams

Category Clinical Vignettes

Concept Herpes Zoster

Concept Varicella-Zoster Virus

Concept Poly-radiculitis

Concept Dermatomal Rash

Concept Vesicular Rash

Distinguished Non-Finalist

Presenter Organization Kent Hospital/Brown University Internal Medicine Program

Presenting Author Carolyn Molina

Track Adult

Keywords

rheumatoid arthritis

adalimumab

varicella zoster virus

VZV reactivation

lumbar polyradiculitis

immunosuppressive therapy

intravenous acyclovir

vesicular rash

MRI spine

lumbar puncture

Herpes Zoster

Varicella-Zoster Virus

Poly-radiculitis

Dermatomal Rash

Vesicular Rash