SHM Converge Scientific Abstract ePoster Gallery-Intracerebral Varicella Zoster Virus Vasculopathy in an Immunocompetent Patient

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A 31-year-old immunocompetent man with a history of narcolepsy, migraine, anxiety, depression, and motor tics presented with 3 days of headache, left-sided weakness, and intermittent left arm paresthesia. Neurologic exam showed decreased left upper extremity sensation but preserved strength. Initial CT and MRI revealed right caudate lacunar infarct and focal right MCA territory infarction with mass effect. MRA demonstrated moderate-to-severe stenosis of the distal M1 and proximal M2 segments of the right MCA, while neck vessels were patent. Echocardiography was largely unremarkable aside from mild-to-moderate left atrial dilation. Hypercoagulable testing and EEG were negative.<br /><br />He was initially treated with dual antiplatelet therapy and discharged, but repeat MRI/MRA one month later showed a new right frontal infarct and marked progression to near-complete occlusion of the right MCA M1 segment. He was readmitted for diagnostic cerebral angiography, which confirmed severe right MCA stenosis with post-stenotic dilation and collateral formation. Lumbar puncture showed lymphocytic pleocytosis and mildly elevated protein. Varicella zoster virus (VZV) was detected in cerebrospinal fluid; serum VZV IgG was elevated, while IgM was low. Other infectious and autoimmune studies (HIV, RPR, ANA, ANCA) were negative.<br /><br />This case highlights intracerebral VZV vasculopathy as a rare but treatable cause of stroke in young patients, even without a preceding rash. The report emphasizes the importance of detailed history, cerebrospinal fluid testing for VZV DNA or antibodies, vascular imaging with MRA or angiography, and follow-up imaging to monitor disease progression. The patient was discharged on intravenous acyclovir for 14 days.

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Amy Pulikeyil

Meta Tag

Author List Amy Pulikeyil, Cristine K. Arcilla, Natalia Plotskaya, Ruth Ramon

Category Clinical Vignettes

Concept Varicella-Zoster Virus Vasculopathy

Concept Intravenous Acyclovir

Concept Ischemic Stroke

Concept VZV DNA

Concept VZV Serology

Distinguished Non-Finalist

Presenter Organization Capital Health Regional Medical Center, Trenton, NJ

Presenting Author Amy Pulikeyil

Track Adult

Keywords

varicella zoster virus

VZV vasculopathy

ischemic stroke

young adult

middle cerebral artery stenosis

cerebrospinal fluid

lymphocytic pleocytosis

intravenous acyclovir

magnetic resonance angiography

intracerebral infection

Varicella-Zoster Virus Vasculopathy

Intravenous Acyclovir

Ischemic Stroke

VZV DNA

VZV Serology