Case 2010 - 6
Julia Kofler, MD, Geoffrey Murdoch, MD PhD
University of Pittsburgh
Clinical history

52 yo male

H/o Hodgkin lymphoma 2006
- Chemotherapy
- Autologous stem cell transplant 02/2009
- Mediastinal radiation 07/2009

09/2009: dyspnea, cough, low-grade fever, chest wall pain and
rash
- Chest x-ray and CT c/w radiation pneumonitis

Mental status changes
- Head CT unremarkable

One day later, patient collapsed, minimally responsive with
seizure-like activity
Diagnosis?
VZV
VZV
VZV infections of the nervous system
 Inflammation, hemorrhage and necrosis in spinal
ganglia
 Polyradiculitis
 Myelitis
 Meningitis
 Encephalitis
- Large vessel disease
- Small vessel vasculopathy
- Ventriculitis/periventriculits
- Mixed patterns
Large vessel disease
 Vessel wall inflammation,
necrotizing vasculitis,
thrombosis
 Bland or hemorrhagic infarctions
in distribution of large or
medium-sized arteries
 Vasculopathy with fibrointimal
proliferation but without
inflammation
 Immunocompetent and
immunosuppressed patients
Kleinschmidt-DeMasters, Arch Pathol Lab Med 2001
Small vessel vasculopathy
 Variable lymphocytic infiltrate and endothelial
swelling
 Often associated with infection of oligodendrocytes
 Mixed ischemic/demyelinating
lesions near cortical gray/white
junction
 Intranuclear viral inclusions
more readily identified
 Lesions often lack
significant inflammation
Kleinschmidt-DeMasters, Arch Pathol Lab Med 2001
Ventriculitis/periventriculitis
 Rare in pure form
 Infection of ependymal cells
VZV ISH
Kleinschmidt-DeMasters, Arch Pathol Lab Med 2001
Final diagnosis
 Varicella zoster radiculitis, meningitis and
vasculitis associated with intraparenchymal
hemorrhage
References

Kleinschmidt-DeMasters BK, Gilden DH. Varicella zoster virus
infections of the central nervous system. Clinical and pathologic
correlates. Arch Pathol Lab Med 2001; 125:770-780

Kleinschmidt-DeMasters BK, Amlie-Lefond C, Gilden DH. The patterns
of Varicella zoster virus encephalitis. Hum Pathol 1996; 27:927-938.

Gilden D, Cohrs RJ, Mahalingham R, Nagel MA. Varicella zoster virus
vasculopathies: Diverse clinical manifestations, laboratory features,
pathogenesis and treatment. Lancet Neurol 2009; 8:731-740.