Teaching NeuroImages: herpes zoster myelitis.

Shyam S. Moudgil, MD Three weeks after developing zoster rash, a 34-yearold, previously healthy woman presented with right arm weakness and gait dysfunction. MRI of the cervical spine revealed abnormal cord signal (figure). CSF demonstrated lymphocytic pleocytosis, elevated immunoglobulin G (IgG) index, and anti–varicella zoster virus (VZV) IgG antibodies. VZV DNA was not detected. She was treated with IV acyclovir and steroids. Herpes zoster myelitis is rare among immunocompetent hosts and is characterized by predominant ipsilateral involvement of spinal segments corresponding to the affected dermatome. Presence of either VZV DNA or anti-VZV IgG in the CSF is diagnostic.1 Treatment with acyclovir and corticosteroids is recommended, based on anecdotal experience.2 Corticosteroids should be used only in combination with acyclovir to prevent viral dissemination.