SHM Converge Scientific Abstract ePoster Gallery-Double Trouble: Neuromyelitis Optica Following Varicella-Zoster Reactivation

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A 39-year-old woman presented with left periorbital pain and a vesicular rash, followed by progressive paresthesia and weakness of the left arm and leg. She had recently traveled to Pennsylvania and upstate New York and denied fever. Exam showed vesicles in the left posterior ear, bradycardia, and hypothermia. CSF analysis revealed lymphocytic pleocytosis and mildly elevated protein, while PCR and culture were negative. She was initially treated empirically for varicella-zoster virus (VZV) reactivation with acyclovir and high-dose steroids, and VZV IgG later returned positive.<br /><br />Despite treatment, her neurologic symptoms worsened over 9 days, with dysmetria and increasing left-sided weakness. MRI showed a T2 hyperintense lesion in the left posterolateral medulla and cervicomedullary junction, suggesting demyelination. Aquaporin-4 IgG (AQP4-IgG) was positive, confirming neuromyelitis optica (NMO). She improved after plasmapheresis and rituximab, returning to baseline within 14 days.<br /><br />This case highlights the diagnostic challenge of distinguishing VZV reactivation from a central demyelinating disorder. NMO is an autoimmune disease caused by AQP4-targeted astrocyte injury and commonly affects the optic nerves and spinal cord. Although the exact mechanism is unclear, infections may trigger NMO. Clinicians should consider NMO in patients with neurologic deficits after recent VZV infection, especially when MRI suggests CNS demyelination. Early diagnosis and prompt immunotherapy are essential to prevent permanent neurologic damage.

Asset Subtitle

Harleen K. Sidhu

Meta Tag

Author List Eduardo Ribas, Harleen K. Sidhu, Mohamed Abdelghffar

Category Clinical Vignettes

Concept Neuromyelitis Optica

Concept Progressive Focal Neurologic Deficit

Concept Aquaporin-4 Antibody

Concept Varicella-Zoster Reactivation

Concept Central Demyelinating Disorder

Distinguished Non-Finalist

Presenter Organization Department of Medicine, NYC Health + Hospitals/Elmhurst, Icahn School of Medicine at Mount Sinai

Presenting Author Harleen K. Sidhu

Track Adult

Keywords

neuromyelitis optica

AQP4-IgG

varicella-zoster virus

vesicular rash

demyelination

medulla lesion

cervicomedullary junction

plasmapheresis

rituximab

lymphocytic pleocytosis

Neuromyelitis Optica

Progressive Focal Neurologic Deficit

Aquaporin-4 Antibody

Varicella-Zoster Reactivation

Central Demyelinating Disorder