A 72-year-old man with metastatic papillary thyroid cancer, Karnofsky Performance Status score of 80, presented with back pain and no motor weakness. His last chemotherapy treatment was 6 months prior to hospital admission and he had a normal complete blood cell count. Magnetic resonance imaging revealed bony metastases at the T4 vertebra with epidural extension and severe spinal canal narrowing. The patient underwent T4 vertebrectomy, decompressive laminectomy, and posterior spine stabilization. He did well after surgery and stood up with assistance until postoperative day 8, when he developed acute right lower extremity weakness with progressive involvement of the left lower and upper extremities over the ensuing 3 days. Magnetic resonance imaging of the spine demonstrated T2 hyperintensity along the left T4 dorsal gray horn (Figure 1C) and extension of the T2 abnormality in the central cord from C7 to T8. A distinct vesicular rash was noticed on the left chest close to the surgical incision (Figure 2). Acyclovir treatment was initiated owing to concern for varicella-zoster virus (VZV) infection on postoperative day 8, with the addition of intravenous immunoglobulin and methylprednisolone on day 10.
Figure 1. Magnetic resonance imaging (MRI) of the spine. A and B, Axial T2-weighted MRI of the spine demonstrating normal thoracic cord signal preoperatively (A) and on postoperative day 6 (B). C, At the onset of paraplegia (postoperative day 8), MRI identified new T2 hyperintensity along the left dorsal gray horn at level T4 (arrow) compatible with the central spread of reactivated varicella-zoster virus at the level of spine surgery. D, Caudal extension of central cord T2 signal abnormality at the T6 level.
Figure 2. Left chest wall vesicular rash.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Neurology editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 1
Customize your page view by dragging & repositioning the boxes below.
More Listings atJAMACareerCenter.com >
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.