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Título

Polyradiculoneuritis by Varicella Zoster Virus (VZV) without cutaneous involvement in a immunocompetent man: a case-report

RESUMO

Case presentation. A 62-year-old healthy man presented with a 3-week history of progressive severe low back pain and weakness. One week after pain onset, he noted progressive proximal weakness in lower limbs and left facial palsy. He had no fever, weight loss, choking or recent travel history. He was evaluated twenty days after the symptoms onset and his neurologic examination showed an MRC grading system (right/left) of: hip flexion 2/2, hip extension 2/3, knee flexion 4-/4, knee extension 4/4, ankle dorsiflexion 5/5 and plantar flexion 5/5, along with mild weakness in the distal upper limbs (UL). Deep tendon reflexes were absent in the LL and normal in the UL. Sensory examination reveled abnormal response to pain and temperature senstionss in the medial aspects of both legs. Vibration was absent on the ankles. There was a left-sided facial palsy House-Brackman (HB) grade III. No skin lesions were seen. Sensory and motor nerve conduction studies were normal in both UL and LL. Needle examination showed diffuse acute denervation affecting the lumbosacral segment bilaterally. Brain MRI showed bilateral facial neuritis, worse on the left. CSF revealed lymphocytic pleocytosis, elevated protein and a CSF/blood glucose ratio of 53%. Spinal MRI had diffuse leptomeningeal thickening and enhancement of thoracic and lumbar nerve roots. He was treated with high doses of oral steroids, with improvement of weakness and pain in the lower limbs. Laboratory results evidenced elevated levels of IgG for Varicella Zoster Virus (VZV) in blood and a 1:8 titer for IgG VZV in CSF. Discussion. We present a rare manifestation of VZV infection with no skin lesions in an immunocompetent patient. VZV remains latent in the sensory ganglia of the peripheral nervous system after a primary infection and can reactivate. Usually, during reactivation, there are papulovesicular skin lesions and neuropathic pain. Some patients show signs of segmental radiculopathy, but polyradiculitis as this patient presented is a very rare manifestation. VZV is also a relevant cause of cranial neuropathy, and the trigeminal and facial nerves are the most frequently affected. Patients often recover from motor deficits. Final comments. The presence of polyradiculoneuritis in immunocompromised patients should include VZV infection as a differential diagnosis. In the absence of immunosuppression and a characteristic skin lesion, diagnosis is challenging and laboratory tests are essential.

Palavras Chave

Varicella Zoster Virus Infection; Polyradiculopathy; Low Back Pain; Middle Aged; Facial Paralysis; Prednisolone;