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Observation | Sep 2012

Fatal Varicella-Zoster Virus Vasculopathy Associated With Adalimumab Therapy

Wonki Baek, MD; Sang-Gon Lee, MD; Young Seo Kim, MD; Jae-Hoon Kim, MD; Jae-Bum Jun, MD, PhD; Hyun Young Kim, MD, PhD

Arch Neurol. 2012;69(9):1193-1196. doi:10.1001/archneurol.2011.3741.

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ABSTRACT

ABSTRACT | REPORT OF A CASE | COMMENT | AUTHOR INFORMATION | REFERENCES

Objective To describe the case of a patient who had been receiving adalimumab for rheumatoid arthritis and died of varicella-zoster virus vasculopathy with multifocal cerebral hemorrhage.

Design Case report.

Setting Hanyang University Hospital, Seoul, Republic of Korea.

Patient A 66-year-old woman with adalimumab therapy for rheumatoid arthritis followed by stuporous mental changes.

Results Magnetic resonance imaging scans showed multifocal parenchymal lesions and hemorrhage in the brainstem and supratentorial areas. Polymerase chain reaction analysis of the cerebrospinal fluid was positive for varicella-zoster virus. The patient died of multifocal vasculopathy despite intensive antiviral and antibacterial medication.

Conclusions Varicella-zoster virus multifocal vasculopathy with encephalitis may be associated with adalimumab therapy. Clinicians should be aware of the possibility of fatal varicella-zoster virus vasculopathy with encephalitis in patients undergoing adalimumab therapy for rheumatoid arthritis.

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Figure 1. Magnetic resonance images on the day of symptom onset. T2-weighted image showing hyperintensities in the dorsal midbrain (A) with lower intensities (arrow). The diffusion-weighted image (B) reveals a ring-shaped restriction, and the T2 gradient-echo image (C) represents a hemorrhagic focus in the left midbrain tectal region.

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Figure 2. Magnetic resonance images on the fifth day after symptom onset. The lesions appear as hyperintense foci, especially in the left ventral pons and midbrain extending to the contralateral medial temporal lobe (A). On T2 gradient-echo images (B and C), the lesions are accompanied by intraparenchymal hemorrhage and multiple microbleeds.

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Baek W, Lee S, Kim Y, Kim J, Jun J, Kim H. Fatal Varicella-Zoster Virus Vasculopathy Associated With Adalimumab Therapy. Arch Neurol. 2012;69(9):1193-1196. doi:10.1001/archneurol.2011.3741.

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Fatal Varicella-Zoster Virus Vasculopathy Associated With Adalimumab Therapy

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