1. Clinicopathologic Conference (CPC) 03/17/17
Neurology Resident: Pouria Moshayedi
Pathologist: Ronald Hamilton

2. History
85 year old male with PMHx of HTN, HLD, A-fib (on eliquis), Prostate Ca, hypothyroidism, hearing loss and idiopathic pulmonary fibrosis (on Esbriet and steroid), who presented from his SNF with a 4 week history of right arm pain.
Right arm pain started after he developed a vesicular rash throughout his entire RUE.
Pain started after increasing dose of prednisone for his SoB and PF.
Diagnosed with shingles of the RUE; treated with valacyclovir/ Valtrex.
Pain was intermittent, spontaneously occurring Q5-15 min, crippling, sharp, burning & shooting from finger to his shoulder.
Refractory to treatment with pregabalin, doluxetine, and nerve block.
Artistic work by Robert Russin, who had post-herpetic neuralgia

3. History
ROS was positive for RUE pain and decreased hearing in right ear
PMH: A-fib, Prostate Ca (s/p radiation seeds), HTN, HLD, Hypothyroidism, IPF, Appendectomy, Lumbar fusion
Medications: Tylenol, pregabalin, doluxetine, Esbriet, prednisone, dig, dilt

4. Examination Labs: Mental Status: Alert, oriented x2. Language intact.
CN: WNL
Motor: Right foot drop for 2-3 months
Sensory: Pain followed C5-C6 distribution. Vibration and pinprick intact in RUE. Hyperesthesia and distorted sensation when tested during spells.
Reflex: No exaggerated or pathologic reflex
Coordination: Mild dysmetria on right
GAIT: UTA
Labs:
WBC 13 (Bandemia of 6-8%). CRP 10. ESR 63. Neg NMO ab.
CSF: Nl OP. WBC 41 (99% Lym), RBC 3, glu 90, protein 54. VZV PCR undetermined. EBV, CMV, HSV1/2 PCRs negative. Neg VDRL and Lyme abs.
Positive anticomplement immunofluorscence for VZV. Negative VZV IgM.

5. Radiology – Sagittal T2
No definite enhancement

6. Radiology – Axial T2 R

7. Examination Labs: Mental Status: Alert, oriented x2. Language intact.
CN: WNL
Motor: Right foot drop for 2-3 months
Sensory: Pain followed C5-C6 distribution. Vibration and pinprick intact in RUE. Hyperesthesia and distorted sensation when tested during spells.
Reflex: No exaggerated or pathologic reflex
Coordination: Mild dysmetria on right
GAIT: UTA
Labs:
WBC 13 (Bandemia of 6-8%). CRP 10. ESR 63. Neg NMO ab.
CSF: Nl OP. WBC 41 (99% Lym), RBC 3, glu 90, protein 54. VZV PCR undetermined. EBV, CMV, HSV1/2 PCRs negative. Neg VDRL and Lyme abs.
Positive anticomplement immunofluorscence for VZV. Negative VZV IgM.

8. Gel electrophoresis on PCR amplified VZV – CSF Sample
C C
Courtesy of Dr. Charles Rinaldo

9. Clinical Course
Pain service recommended Tylenol, ibuprofen and Lidoderm.
Increasing doluxetine and pregabalin, and adding oxcarbazepine led to some improvement.
Started acyclovir after CSF pleocytosis.
Transferred to Medical ICU on day 3 following respiratory distress. Started on antibiotics for possible PNA (question of VZV pneumonitis?).
Made CMO. Passed away on hospital day 6.

10. Differential Diagnosis
Pain: Post-herpetic neuralgia
Cord signal change/CSF pleocytosis:
VZV myelitis: No sensory or motor finding suggesting myelopathy
VZV radiculitis
Metabolic: B12/D/E/Cu/B1 deficiency
Other infections: not sent for fungal culture. Other viral/lyme studies neg
Vascular: infarction and malformations/fistula unlikely with normal exam
Demyelination/autoimmune: unlikely for his age. NMO ab neg.
Idiopathic myelopathy
Chronic signal change, clinically insignificant, related to possible trauma

11. Predicted Pathology – Optical Microscope
If VZV Myelitis:
Perivascular inflammation and vasculitis
Necrosis
Meningitis
Kleinschmidt-DeMasters and Gilden, Arch Pathol Lab Med 2001

12. Predicted Pathology – Electron Microscope
Cowdry Type A intranuclear inclusion bodies in oligodendrocytes
Intracytoplasmic Virion and capsid inclusion bodies in white matter cells.
Hogan and Krigman, Arch Neurol 1973

13. CD68

14. CS Tract
CD88
CD68
CD4

15. Dorsal Root Entry
CD8
CD68
CD4

16. Anti-VZV

17. CD68