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Abstract Details

Isolated Unilateral Oculomotor Nerves Involvement: an Atypical Presentation of VZV Reactivation
Infectious Disease
Infectious Disease Posters (7:00 AM-5:00 PM)
032
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Central nervous system Varicella Zoster Virus (VZV) infection typically manifests with meningitis, meningoencephalitis, myelitis, meningoradiculitis, and vasculopathy. Cranial nerve (CN) involvement typically occurs in association with a skin rash. We report the unusual presentation of isolated CN III and IV involvement due to VZV reactivation in an immunocompetent patient, broadening the phenotypic spectrum of neurological manifestations of VZV.

A 45 years old man without significant past history presented for acute unusual headache and binocular diplopia. Physical examination showed paralysis of the left medial and superior rectus and inferior oblique muscles, along with a semi-reactive pupil on the left and convergence insufficiency. Neck was subtle. Patient was slightly somnolent but easily arousable. Fundus exam did not show evidence of papillary edema. No skin lesions were identified. Brain MRI with contrast was normal. CSF analysis showed mild pleocytosis (white blood cells 45/mm3, lymphocyte 80%), mildly elevated protein (0.68g/L), normal glucose (3mmol/L), and negative bacterial cultures and syphilis screen. Viral PCR testing in the CSF was positive for VZV. Serum VZV IgG were highly positive, IgM were negative. An extensive autoimmune panel was negative except for positive ANA (titer: 1/320). The patient was treated with intravenous Acyclovir 800mg q8h for 10 days with near complete resolution of his headache and diplopia at day 10. Follow-up at day 25 showed residual cranial IV involvement with complete resolution of cranial nerve III-attributed opthalmoparesis.

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We report a rare presentation of VZV cranial polyneuropathy without associated skin rash. Here, CN involvement was not attributable to intracranial hypertension. Transaxonal viral spread along ganglionic fibers causing microinfarction of CN has been hypothesized. Previous cases of isolated diplopia with CN III and CN IV involvement and without rash are rare. VZV infection should be in the differential diagnosis of isolated occulomotor polyneuropathy without rash even in immunocompetent individuals.

Authors/Disclosures

PRESENTER 		No disclosure on file
Christian Matta Christian Matta has nothing to disclose.
Gabrielle Macaron, MD Dr. Macaron has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Novartis . Dr. Macaron has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Roche. Dr. Macaron has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Biogen. Dr. Macaron has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for EMD-Serono. Dr. Macaron has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Roche. Dr. Macaron has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Novartis. Dr. Macaron has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for MedEdge. Dr. Macaron has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Novartis. The institution of Dr. Macaron has received research support from National MS Society/International Progressive Multiple Sclerosis Alliance .