A CURIOUS CASE OF THE “POX” STROKE R Panicker MD, H Sajjad MD, A Ajit MD, JK Khera DO, S Shahid MD, N Sells MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA INTRODUCTION: There has been an increasing incidence of strokes caused by reactivation of varicella-zoster virus (VZV) in both immunocompetent and immunocompromised hosts. Multiple case reports have demonstrated a link between stroke and zoster virus. Recent studies have emerged which reveal that VZV infection of the cerebral arteries directly causes pathological vascular remodeling and stroke (VZV vasculopathy). CASE: A 60-year-old man with uncontrolled diabetes, hypertension, and herpes zoster ophthalmicus (HZO) presented with right sided weakness. He was initially diagnosed with HZO six months prior and was treated with oral acyclovir for seven days. During his current admission his main deficits included right sided upper and lower extremity weakness along with right sided facial drooping. Contrast tomography of the head and angiography of the head and neck did not reveal any acute intracranial abnormality or large vessel occlusion. Of note, he was hospitalized two weeks prior to his current presentation with similar symptoms. Magnetic resonance imaging demonstrated a left pontine ischemic stroke and a lumbar puncture was positive for VZV IgG in the cerebrospinal fluid (CSF). He was treated with intravenous (IV) acyclovir 800 milligrams three times a day (TID) for fourteen days and afterwards was discharged. Infectious diseases and neurology services were consulted. Neurology recommended treating as a primary small vessel vasculitis with Methylprednisolone 1000 milligrams for five days without a taper. Infectious disease recommended acyclovir 800 milligrams TID as inpatient with an additional 14 days on discharge. He had significant improvement in his right sided weakness following treatment and was discharged to inpatient rehabilitation for further physical therapy and outpatient follow up with ophthalmology for his HZO. DISCUSSION: Several meta-analyses showed stroke risk is significantly increased shortly after acute zoster infection and remains elevated for up to one year. Herpes zoster ophthalmicus increases stroke risk by a larger magnitude. There is a growing consensus that VZV stroke presents as a small vessel vasculitis which necessitates treatment with pulse dose steroids as in such cases treatment with antivirals alone may not be enough.
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