Abstract
The triggering effect of herpes simplex virus infection on the development of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is now well established. However, there are very few reports that has linked a varicella zoster virus (VZV) reactivation with anti-NMDAR encephalitis. In this report, we describe a case of a 57-year-old man presented with atypical clinical presentation of anti-NMDAR encephalitis with gait ataxia, complete ophtalmoplegia, and abolished reflexes followed by drowsiness and confusion. Initial diagnosis of Bickerstaff’s brainstem encephalitis was suspected. Few days later, the patient developed herpes zoster in a localized right T1-T2 dermatome. Cerebrospinal fluid (CSF) polymerase chain reaction (PCR) for VZV was negative. CSF anti-NMDA antibodies were proved positive. A diagnosis of anti-NMDAR encephalitis with concomitant VZV skin reactivation was retained. Favorable outcome with combined antiviral treatment and immunomodulatory therapy was observed. Concomitant VZV reactivation with autoimmune encephalitis is possible. Prognosis and therapeutic options in this rare condition remain to be clarified.
Similar content being viewed by others
References
Becerra JCL, Sieber R, Martinetti G, Costa ST, Meylan P, Bernasconi E (2013) Infection of the central nervous system caused by varicella zoster virus reactivation: a retrospective case series study. Int J Infect Dis IJID Off Publ Int Soc Infect Dis 17:e529-534. https://doi.org/10.1016/j.ijid.2013.01.031
Gregoire SM, van Pesch V, Goffette S, Peeters A, Sindic CJM (2006) Polymerase chain reaction analysis and oligoclonal antibody in the cerebrospinal fluid from 34 patients with varicella-zoster virus infection of the nervous system. J Neurol Neurosurg Psychiatry 77:938–942. https://doi.org/10.1136/jnnp.2006.090316
Horton E, Krishnamoorthy S, Reynolds L (2014) Bickerstaff’s encephalitis. BMJ Case Rep. https://doi.org/10.1136/bcr-2014-205336
Ishikawa Y, Ikeda K, Murata K, Hirayama T, Takazawa T, Yanagihashi M, Kano O, Kawabe K, Takahashi Y, Iwasaki Y (2013) Ophthalmoplegia and flaccid paraplegia in a patient with anti-NMDA receptor encephalitis: a case report and literature review. Intern Med 52:2811–2815. https://doi.org/10.2169/internalmedicine.52.1065
Kennedy PG, Mogensen TH (2020) Determinants of neurological syndromes caused by varicella zoster virus (VZV). J Neurovirol 26:482–495. https://doi.org/10.1007/s13365-020-00857-w
Kleines M, Scheithauer S, Schiefer J, Häusler M (2014) Clinical application of viral cerebrospinal fluid PCR testing for diagnosis of central nervous system disorders: a retrospective 11-year experience. Diagn Microbiol Infect Dis 80:207–215. https://doi.org/10.1016/j.diagmicrobio.2014.07.010
Nagane Y, Utsugisawa K, Obara D (2006) Case of herpes zoster associated Guillain-Barré syndrome with a relapse of eruptions after intravenous immunoglobulin therapy. Rinsho Shinkeigaku 46:664–667 PMID: 17260813
Nagel MA, Gilden D (2013) Complications of varicella zoster virus reactivation. Curr Treat Options Neurol 15:439–453. https://doi.org/10.1007/s11940-013-0246-5
Prakash PA, Jin J, Matharu K, Garg T, Tsai WC, Patel P, Weatherhead JE, Kass JS (2018) Anti-NMDAR encephalitis with concomitant varicella zoster virus detection and nonteratomatous malignancy. Neurol Neuroimmunol Neuroinflammation. https://doi.org/10.1212/NXI.0000000000000537
Schäbitz W-R, Rogalewski A, Hagemeister C, Bien CG (2014) VZV brainstem encephalitis triggers NMDA receptor immunoreaction. Neurology 83:2309. https://doi.org/10.1212/WNL.0000000000001072
Solís N, Salazar L, Hasbun R (2016) Anti-NMDA Receptor antibody encephalitis with concomitant detection of varicella zoster virus. J Clin Virol Off Publ Pan Am Soc Clin Virol 83:26–28. https://doi.org/10.1016/j.jcv.2016.08.292
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare no competing interests.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Fatma, N., Zakaria, S., Mourad, Z. et al. Atypical anti-NMDA receptor encephalitis associated with varicella zoster virus infection. J. Neurovirol. 28, 456–459 (2022). https://doi.org/10.1007/s13365-022-01080-5
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13365-022-01080-5