Introduction. Zoster is a well-known risk factor for stroke. Varicella zoster virus (VZV) can infect cerebral arteries after re-activation. VZV-vasculopathy is challenging because of heterogeneous and evolving phenotype and possible unfavourable course without prompt treatment. We report a prototypical case.
Case-Report. A 84-year-old healthy and immunocompetent woman referred to emergency department because of confusional state during fever. Under supervision she presented a tonic-clonic seizure of left limbs followed by persistent vigilance impairment, left side hemiparesis with anesthesia and right-forced gaze version. During previous month she suffered right ear pain and deafness without local rash and progressive cognitive impairment. Head CT scan showed a right medial frontal hypo-density and EEG showed background slow activity with right sharp waves. Otoscopy showed a recent right middle ear acute otitis. Carotid and heart ultrasound, ECG, blood exams were unremarkable. Cerebrospinal fluid (CSF) exam showed 3 lymphocytes and normal protein and glucose concentrations, whereas PCR revealed the presence of VZV-DNA. Acyclovir, prednisone and levetiracetam were introduced, associated to aspirin. Brain MRI and angiography studies showed an ischemic stroke in the territory of an irregular right anterior cerebral artery and diffuse post-gadolinium leptomeningeal enhancement. After three-months follow-up, patient was well oriented with mild gaze impairment and left side hemiparesis.
Conclusions. VZV-vasculopathy should be suspected not only in stroke patients with history of Zoster but also in atypical stroke presentations associated with a recent evolving cranial neuralgia or encephalopathy; immunosuppression is not a prerequisite especially in older patients. VZV-DNA search on CSF should be performed.