Figure 1
Sagittal T1-weighted image of the cervical spine
Sagittal spin-echo T1-weighted image of the cervical spine shows slight thickening of the cord at C3 through C5 levels, without abnormal signal intensity.
Clinical History
The patient presented with left arm weakness and sensory loss, three months after treatment for herpes zoster.
Imaging Findings
The patient presented with sudden left arm weakness and sensory loss. Three months earlier she had been treated for herpes zoster of the left upper arm, occiput and neck. Five days prior to admission she developed a nonspecific left arm skin rash. Deep tendon reflexes were brisk in the left arm; pain, light touch, position and vibration sensations were decreased in the C4-5 dermatomal distribution. CSF contained 9 mononuclear cells and slightly elevated proteins. EMG showed a severe radicular lesion at the C5 and C6 level on the left.
Cervical spine MR imaging revealed a high-signal-intensity spinal cord lesion on T2-weighted images, involving C3 to C5 segments, predominantly in the grey matter on the left. The lesion showed no contrast enhancement.
The patient was started on intravenous acyclovir and dexamethasone, and her neurological deficits started to disappear.
Cervical spine MR imaging revealed a high-signal-intensity spinal cord lesion on T2-weighted images, involving C3 to C5 segments, predominantly in the grey matter on the left. The lesion showed no contrast enhancement.
The patient was started on intravenous acyclovir and dexamethasone, and her neurological deficits started to disappear.
Discussion
Herpes zoster represents a reactivation of latent varicella zoster virus (VZV) infection and is usually manifested as peripheral or cranial neuropathy. Defective cellular immunity may increase the likelihood of VZV reactivation (1), e.g. in patients with lymphoma, leukaemia, the acquired immune deficiency syndrome, metastatic cancer, or systemic lupus erythematosus. Myelitis is a rare neurological complication of herpes zoster, which is diagnosed based on the close temporal relationship between the onset of skin lesions and myelitis. The pathogenesis may be direct viral invasion of the cord, vasculitis with ischaemic necrosis, or an immunological-parainfectious mechanism (2). Direct invasion is often inferred from the eccentric location of the enhancement near the dorsal root entry zone, and the correspondence between the level of the cord lesion and the dermatomal distribution of the skin lesions in a patient with shingles. VZV has been isolated from the brain and spinal cord, thus indicating that direct invasion does occur. Clinical findings after acute VZV infection usually include self-limited paraparesis, with or without sensory loss and sphincter dysfunction. MRI findings in documented cases (4,5) of VZV myelitis include diffuse hyperintensity on T2-weighted images that extends over several levels and probably represents oedema, as well as less extensive focal or multifocal enhancement on post-contrast T1-weighted images, which may represent direct viral invasion or blood-cord barrier breakdown. The clinical course of zoster myelitis is quite variable: acute, subacute, chronic, or remitting exacerbating myelopathy have all been described. The prognosis ranges from benign and self-limiting to progressive and fatal. This variability may in part be ascribed to the possible diverse pathological mechanisms of injury, as mentioned above. Early therapeutic intervention with acyclovir prevents multiplication and spread of the virus in the spinal cord, and, together with absence of serious predisposing disease, contributes to good prognosis (3).
To the best of our knolwedge there have been no previous reports of varicella-zoster myelitis affecting predominantly the grey matter.
To the best of our knolwedge there have been no previous reports of varicella-zoster myelitis affecting predominantly the grey matter.
Differential Diagnosis List
Varicella-Zoster myelitis
Final Diagnosis
Varicella-Zoster myelitis
References
[1]
1. Straus SE.
Overview: the biology of varicella-zoster virus infection.
Ann Neurol. 1994;35 Suppl:S4-8. (PMID: 8185296)
[2]
2. Devinsky O, Cho ES, Petito CK, Price RW.
Herpes zoster myelitis.
Brain. 1991 Jun;114(Pt 3):1181-96. (PMID: 1648419)
[3]
3. Elliott KJ.
Other neurological complications of herpes zoster and their management.
Ann Neurol. 1994;35 Suppl:S57-61. (PMID: 8185301)
[4]
4. Baik JS, Kim WC, Heo JH, Zheng HY.
Recurrent herpes zoster myelitis.
J Korean Med Sci. 1997 Aug;1(4):360-3. (PMID: 9288637)
[5]
5. Nakano T, Awaki E, Araga S, Takai H, Inoue K, Takahashi K.
Recurrent herpes zoster myelitis treated with human interferon alpha: a case report.
Acta Neurol Scand. 1992 May; 85(5):372-5. (PMID: 1320320)
Case information
| URL: | https://www.eurorad.org/case/2218 |
| DOI: | 10.1594/EURORAD/CASE.2218 |
| ISSN: | 1563-4086 |
Figure 2
T2-weighted images in the sagittal plane
Mid-sagittal fast spin-echo T2-weighted image of the cervical spine again shows slight thickening of the cord, with thin linear hyperintensity.
Adjacent sagittal T2-weighted image of the cervical spine, to the left of Figure 2a, shows hyperintense central lesion, extending from C3 to C5 levels (arrow).
Figure 3
Sagittal STIR image of the cervical spine
On sagittal STIR image of the cervical spine, at approximately the same level as in Figure 2b, the lesion is more conspicuous.
Figure 4
Axial T2-weighted images of the cervical spine
Axial gradient-echo T2-weighted image at C3 level shows slightly enlarged left hemicord, with increased signal intensity, predominantly affecting the grey matter (arrow).
Axial gradient-echo T2-weighted image at C4 level again shows slightly enlarged and hyperintense left hemicord, predominantly in the grey matter (arrow). The findings are more conspicuous compared with Figure 4a.
Axial gradient-echo T2-weighted image at C5 level again reveals thickened hyperintense left side of the spinal cord, especially the grey matter (arrow).
Sagittal T1-weighted image of the cervical spine
Sagittal spin-echo T1-weighted image of the cervical spine shows slight thickening of the cord at C3 through C5 levels, without abnormal signal intensity.
T2-weighted images in the sagittal plane
Mid-sagittal fast spin-echo T2-weighted image of the cervical spine again shows slight thickening of the cord, with thin linear hyperintensity.
Adjacent sagittal T2-weighted image of the cervical spine, to the left of Figure 2a, shows hyperintense central lesion, extending from C3 to C5 levels (arrow).
Sagittal STIR image of the cervical spine
On sagittal STIR image of the cervical spine, at approximately the same level as in Figure 2b, the lesion is more conspicuous.
Axial T2-weighted images of the cervical spine
Axial gradient-echo T2-weighted image at C3 level shows slightly enlarged left hemicord, with increased signal intensity, predominantly affecting the grey matter (arrow).
Axial gradient-echo T2-weighted image at C4 level again shows slightly enlarged and hyperintense left hemicord, predominantly in the grey matter (arrow). The findings are more conspicuous compared with Figure 4a.
Axial gradient-echo T2-weighted image at C5 level again reveals thickened hyperintense left side of the spinal cord, especially the grey matter (arrow).