Varicella zoster virus infection presenting as isolated diplopia: a case report

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Abstract

Background

Involvement of trochlear nerve during Varicella Zoster Virus (VZV) Infection has been rarely described, and always in association with skin rash.

Case presentation

We describe the case of a patient with VZV infection presenting as isolated diplopia due to fourth cranial nerve palsy. The diagnosis has been obtained through the application of a standardized molecular diagnostic panel, and diplopia resolved after specific antiviral and corticosteroid therapy.

Conclusion

This case evidences that clinicians should be aware of atypical VZV infection, even in the absence of the typical skin rash.

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Most cited references 5

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The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America.

Allan Tunkel, Carol A Glaser, Karen Bloch … (2008)

Guidelines for the diagnosis and treatment of patients with encephalitis were prepared by an Expert Panel of the Infectious Diseases Society of America. The guidelines are intended for use by health care providers who care for patients with encephalitis. The guideline includes data on the epidemiology, clinical features, diagnosis, and treatment of many viral, bacterial, fungal, protozoal, and helminthic etiologies of encephalitis and provides information on when specific etiologic agents should be considered in individual patients with encephalitis.

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Varicella zoster virus vasculopathies: diverse clinical manifestations, laboratory features, pathogenesis, and treatment.

Don Gilden, Randall Cohrs, Ravi Mahalingam … (2009)

Vasculopathies caused by varicella zoster virus (VZV) are indicative of a productive virus infection in cerebral arteries after either reactivation of VZV (shingles) or primary infection (chickenpox). VZV vasculopathy can cause ischaemic infarction of the brain and spinal cord, as well as aneurysm, subarachnoid and cerebral haemorrhage, carotid dissection, and, rarely, peripheral arterial disease. VZV vasculopathy in immunocompetent or immunocompromised individuals can be unifocal or multifocal with deep-seated and superficial infarctions. Lesions at the grey-white matter junction on brain imaging are a clue to diagnosis. Involvement of both large and small arteries is more common than that of either alone. Most patients have a mononuclear cerebrospinal fluid pleocytosis, often with red blood cells. Cerebrospinal fluid pleocytosis and rash are absent in about a third of cases. Anti-VZV IgG antibody in the cerebrospinal fluid is found more frequently than VZV DNA. In recent years, the number of recognised VZV vasculopathies has grown, and accurate diagnosis is important for the effective treatment of these disorders.

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Infectious encephalitis in france in 2007: a national prospective study.

, Jean-Paul Stahl, Alexandra Mailles (2009)

Encephalitis is associated with significant mortality and morbidity, but its cause remains largely unknown. We designed a national prospective study in France in 2007 to describe patients with encephalitis, investigate the etiologic diagnosis of encephalitis, and assess risk factors associated with death. Patients were enrolled by attending physicians according to case definition, and data were collected with a standardized questionnaire. The etiologic diagnosis was investigated after a standardized procedure. Risk factors associated with death during hospitalization were assessed by multivariate logistic regression. A total of 253 patients with acute infectious encephalitis from 106 medical units throughout France were included in the study. Their ages ranged from 1 month to 89 years (median age, 54 years); 61% were male. Cause of the encephalitis was determined in 131 patients (52%). Herpes simplex virus 1 (42%), varicella-zoster virus (15%), Mycobacterium tuberculosis (15%), and Listeria monocytogenes (10%) were the most frequently identified agents. Twenty-six patients (10%, all adults) died, 6 of them with tuberculosis and 6 with listeriosis. Risk factors independently associated with death during hospitalization identified by the multivariable analysis were age (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.0-1.4; for 5-year increase), cancer (OR, 17; 95% CI, 2.3-122.6), immunosuppressive treatment before onset (OR, 24; 95% CI, 1.3-426.0), percentage of hospitalized patients receiving mechanical ventilation (OR, 2.0; 95% CI, 1.4-3.0; for 10% increase), the etiologic agent, coma on day 5 after admission (OR, 16; 95% CI, 2.8-92.3), and sepsis on day 5 after admission (OR, 94; 95% CI, 4.9-1792.2). Our prospective study provides an overview of the clinical and etiologic patterns of acute infectious encephalitis in adults in France. Herpes simplex virus 1 remains the main cause of encephalitis, but bacteria accounts for the highest case-fatality rates.

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Author and article information

Contributors

Raffaella Pisapia

Alessia Rianda

Andrea Mariano

Angela Testa

Simonetta Galgani

Laura Vincenzi

Amina Abdeddaim

Alessandra Oliva

Pasquale Narciso

Journal

Journal ID (nlm-ta): BMC Infect Dis

Journal ID (iso-abbrev): BMC Infect. Dis

Title: BMC Infectious Diseases

Publisher: BioMed Central

ISSN (Electronic): 1471-2334

Publication date Collection: 2013

Publication date (Electronic): 15 March 2013

Volume: 13

Page: 138

Affiliations

[1 ]Clinical Department, First Division, National Institute for Infectious Diseases “Lazzaro Spallanzani”, Via Portuense 292, 00149, Rome, Italy

[2 ]Neuroscience Department, “San Camillo Forlanini” hospital, Rome, Italy

Article

Publisher ID: 1471-2334-13-138

DOI: 10.1186/1471-2334-13-138

PMC ID: 3605254

PubMed ID: 23497310

SO-VID: 4e19d812-eb00-4771-a4e9-ae96f703d0e4

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Varicella zoster virus infection presenting as isolated diplopia: a case report

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Abstract

Background

Case presentation

Conclusion

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Most cited references 5

The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America.

Varicella zoster virus vasculopathies: diverse clinical manifestations, laboratory features, pathogenesis, and treatment.

Infectious encephalitis in france in 2007: a national prospective study.

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