A 45-year-old woman presented a sudden reduction in the left visual acuity and evolved with amaurosis in 48 hours. Central retinal artery and vein occlusion were confirmed by angiofluoresceinography, with secondary involvement of the optic nerve. Brain and orbital tomography, echocardiography, carotid and vertebral Doppler and 24-hour Holter were unremarkable. One month after, she developed subacute paraparesis, low back pain with irradiation to the lower limbs and urinary and fecal retention. The left eye remained without light perception, and the fundoscopy showed improvement of the blurring of the disc margins and diffuse exudates, including the macula. She had an absent direct photomotor reflex in the left eye, proximal asymmetric paraparesis, tactile and painful sensory level in T10, painful anesthesia in the lower limbs, right Babinski sign and exhaustible bilateral achilles clonus. She needed bladder catheterization.
Spinal magnetic resonance demonstrated longitudinally extensive myelitis (T9-T12) and CSF analysis showed 125 cells/mm³ (88% mononuclear), protein of 261 mg/dL, and HSV PCR positive. Serum anti-HSV 1 IgG was positive and anti-HSV 2 IgG was negative. She was diagnosed with HSV myeloradiculitis and submitted to therapy with acyclovir, methylprednisolone, gabapentin and panretinal photocoagulation. She had partial improvement of the strength and pain in the lower limbs, as well as CSF patterns. However, she remained with amaurosis in the left eye and urinary and fecal retention.