PP04.2 – 2598: The varicella-zoster virus vasculopathy: Case report

Objectives Varicella zoster virus (VZV) is a common childhood infection. Reactivation may cause various neurological complications, including infection of cerebral arteries, resulting in vascular remodeling and stroke. We are presenting an unusual pediatric case of VZV vasculopathy. Case report A six years old boy, with no history of immunologic or neurologic disorder, was admitted to our hospital due to two episodes of diplopia and gait unsteadiness. No history of severe headaches was noted. He had chickenpox 20 months earlier and no history of zoster rash. Physical examination revealed only mild torticollis. Ophthalmological examination was unremarkable. On magnetic resonance imaging (MRI) multiple T2/FLAIR hyperintensities were seen, most pronounced was in the ventral part of the right thalamus, and an old ischemic lesion in the left postcentral cortex, suggesting ischemic lesions of different ages. MR angiography was unremarkable. Cerebrospinal fluid (CSF) pleocytosis was present and it tested positive for VZV DNA; specific anti-VZV antibodies were not detected. Thrombophilia screening revealed he was homozygous for methylenetetrahydrofolate (MTHFR) gene mutation. Fourteen day treatment with intravenous acyclovir was applied. After three months the follow-up MRI showed two old lacunar ischemic lesions and multiple T2/FLAIR hyperintensities at the same locations, new lesions were not found. Symptoms have not reoccurred. Conclusion Our patient had an atypical clinical presentation of multifocal, probably small artery vasculopathy and subsequent ischemic strokes presumably after VZV reactivation wihout the preceding rash.