Makindo Medical Notes

Related Subjects: |Herpes Varicella-Zoster (Shingles) Infection |Chickenpox Varicella Infection |Varicella Cerebral Vasculopathy |Herpes Viruses |Herpes Zoster Ophthalmicus (HZO) Shingles

Introduction

• 🦠 A viral-induced vasculopathy with vascular inflammation due to either initial chickenpox infection or later reactivation of VZV.
• 🧠 Can lead to ischaemic stroke, spinal cord infarction, aneurysm formation, subarachnoid or intracerebral haemorrhage, and carotid dissection.
• 🦵 Rarely, it causes peripheral arterial disease. It may occur without rash, with diagnosis confirmed by detecting Anti-VZV IgG in CSF.

⚡ Key teaching point: VZV vasculopathy may present without skin lesions ("zoster sine herpete") — don’t exclude it just because there’s no rash.

Aetiology

• 👶 Primary VZV infection = chickenpox. Virus then lies dormant in dorsal root ganglia.
• 🔄 Reactivation later in life/immunosuppression → shingles (herpes zoster).
• 🧬 Inflammation affects large & small arteries; granulomatous angiitis can occur.
• 📆 Vasculopathy can appear up to 6 months after infection → evidence of chronic arterial injury.
• 👩‍⚕️ Occurs in both immunocompetent and immunocompromised patients, often multifocal.
• 🚫 No proven association between VZV and giant cell arteritis.

Clinical Features

• 🤕 Headache, fever, malaise → followed by focal neurological deficits (stroke/myelopathy).
• 👁️ Monocular visual loss (central retinal artery occlusion).
• 🧠 Complications: retinal necrosis, cerebellitis, post-herpetic neuralgia.
• ❌ Rash may be absent (zoster sine herpete).
• 🧲 Ipsilateral infarcts can accompany zoster infection.
• 🦵 VZV myelitis may cause long tract signs (UMN features).

📝 Exam Pearl: Think of VZV vasculopathy in a patient with stroke + recent shingles (especially ophthalmic distribution).

Investigations

• 🧪 Anti-VZV IgM: Active infection marker.
• 🖥️ Brain Imaging: Usually abnormal. Ovoid lesions at grey-white junction typical.
• 🩻 Angiography: Stenosis, occlusion, “string-of-beads” narrowing, post-stenotic dilatation. Aneurysms in HIV patients.
• 🧲 CEMRA: Vessel wall thickening & contrast enhancement.
• 💉 CSF:
  • Mild pleocytosis (10–100 WCC/µL).
  • Oligoclonal bands with anti-VZV IgG.
  • Anti-VZV IgG more reliable than VZV DNA PCR.
  • ❌ Negative anti-VZV IgG = rules out VZV vasculopathy.

Management

• 🏥 Standard stroke care (ABCs, admit to HASU).
• 💉 IV Aciclovir 10 mg/kg TDS × 14 days (minimum).
• 💊 Add Prednisolone 1 mg/kg × 5 days to reduce inflammation.

🌟 Clinical takeaway: Early antiviral therapy is crucial. Delayed diagnosis risks multifocal infarcts and poor outcome.

References

• Varicella zoster virus vasculopathies: diverse clinical manifestations, Lancet Neurol. 2009
• Herpes zoster and stroke risk: systematic review & meta-analysis