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Images in Neurology |

Postoperative Varicella-Zoster Virus Myelopathy and Dissemination

Nandita Guha-Thakurta, MD; Bich N. Dang, MD; Syed Azeem, MD; J. Matthew Debnam, MD; Sudhakar Tummala, MD
Arch Neurol. 2011;68(10):1340-1341. doi:10.1001/archneurol.2011.741.
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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.

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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.

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Figure 2. Left chest wall vesicular rash.

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