Dados do Trabalho

Título

Varicella Zoster Myelopathy unmasked by a immune reconstitution inflammatory syndrome: A case Report

RESUMO

A 57-year-old woman living with HIV and with previous poor adherence to treatment started regular use of antiretroviral drugs in December 2021 after pneumocystosis. In January 2022, she started a right frontal throbbing headache and vertigo. Afterwards, she developed paresthesia, progressive crural paraparesis, urinary urge incontinence, right hearing loss with pulsatile tinnitus. The neurologic examination showed spastic crural paraparesis, hypoaesthesia and decrease vibratory sense at the T8 level, a left horizontal torsional nystagmus and an abnormal right head impulse test. The cerebrospinal fluid analysis showed a lymphomononuclear pleocytosis and a positive Varicella-Zoster RT-PCR. The magnetic resonance imaging (MRI) demonstrated T2-FLAIR right vestibulocochlear nerve hyperintense signal and spinal cord hyperintensity at the T1-T2 and T4 levels. We started treatment with acyclovir for 21 days, with just mild neurologic improvement. During the investigation, an important increase in the CD4 lymphocyte count was found (12,2 cell/mm3 in December to 300 cell/mm3 in February). Immune reconstitution inflammatory syndrome (IRIS) was suspected, and a 1 g intravenous methylprednisolone pulse therapy was prescribed for 5 days with a significant improvement of bladder symptoms, gait, and proprioception. She was discharged from the hospital walking with no support. IRIS consists of an increase in T-cell lymphocyte counts resulting in a dysregulated immune response against infecting pathogens and the host, concomitantly. The incidence of this condition changes according to the pathogen, being more common in tuberculosis and Cryptococcosis. Our patient presented an increase of CD4 lymphocyte count associated with new neurological symptoms and abnormal imaging exams and evolved with mild improvement after adequate treatment of the Varicella-Zoster virus. As immune reconstitution inflammatory syndrome was suspected, steroid treatment was prescribed to reconstitute the blood-brain barrier and decrease the response of T lymphocytes. Afterwards, a great clinical improvement was noticed. There is no previous report of a Varicella Zoster myelopathy unmasked in this scenario and with a great response to steroids, resembling the importance of the recognition of this important condition.

Palavras Chave

Varicella Zoster, Myelopathy, immune reconstitution inflammatory syndrome.