Case 2010 - 6
Julia Kofler, MD, Geoffrey Murdoch, MD PhDUniversity of Pittsburgh
Clinical history
52 yo male H/o Hodgkin lymphoma 2006
- Chemotherapy- Autologous stem cell transplant 02/2009- Mediastinal radiation 07/2009
09/2009: dyspnea, cough, low-grade fever, chest wall pain and rash
- Chest x-ray and CT c/w radiation pneumonitis Mental status changes
- Head CT unremarkable One day later, patient collapsed, minimally responsive with
seizure-like activity
Diagnosis?
VZV
VZV
VZV infections of the nervous system
Inflammation, hemorrhage and necrosis in spinal ganglia
Polyradiculitis Myelitis Meningitis Encephalitis
- Large vessel disease- Small vessel vasculopathy- Ventriculitis/periventriculits- Mixed patterns
Large vessel disease
Vessel wall inflammation, necrotizing vasculitis, thrombosis
Bland or hemorrhagic infarctions in distribution of large or medium-sized arteries
Vasculopathy with fibrointimal proliferation but without inflammation
Immunocompetent and immunosuppressed patients
Kleinschmidt-DeMasters, Arch Pathol Lab Med 2001
Small vessel vasculopathy
Variable lymphocytic infiltrate and endothelial swelling
Often associated with infection of oligodendrocytes Mixed ischemic/demyelinating
lesions near cortical gray/whitejunction
Intranuclear viral inclusionsmore readily identified
Lesions often lack significant inflammation Kleinschmidt-DeMasters, Arch Pathol Lab Med 2001
Ventriculitis/periventriculitis
Rare in pure form Infection of ependymal cells
Kleinschmidt-DeMasters, Arch Pathol Lab Med 2001
VZV ISH
Final diagnosis
Varicella zoster radiculitis, meningitis and
vasculitis associated with intraparenchymal
hemorrhage
References
Kleinschmidt-DeMasters BK, Gilden DH. Varicella zoster virus infections of the central nervous system. Clinical and pathologic correlates. Arch Pathol Lab Med 2001; 125:770-780
Kleinschmidt-DeMasters BK, Amlie-Lefond C, Gilden DH. The patterns of Varicella zoster virus encephalitis. Hum Pathol 1996; 27:927-938.
Gilden D, Cohrs RJ, Mahalingham R, Nagel MA. Varicella zoster virus vasculopathies: Diverse clinical manifestations, laboratory features, pathogenesis and treatment. Lancet Neurol 2009; 8:731-740.