We describe a case of acute varicella-zoster virus (VZV) hemorrhagic meningoencephalomyelitis in an HIV-infected patient. On admission the patient's CSF was mild haemorrhagic and xanthochromic after centrifugation and he had thoracic skin blisters. VZV DNA was isolated from both the thoracic blisters and CSF. Treatment consisted of aggressive antiviral, steroid and immunoglobulin therapy, which was able to stop disease progression. The patient survived but was left blind and paretic. In conclusion, a diagnosis of CNS infection caused by VZV, based upon CSF analysis and examination of the skin for typical blisters, requires aggressive empiric antiviral therapy in order to maximise patient survival

Carlo Tascini

Enrico Tagliaferri

Francesco Menichetti

Jessica Mencarini

Marina Polidori

Paola Lambelet

Sarah Flammini

Serena Fondelli

Umberto Vetrano

Tascini, Carlo

Polidori, Marina

Flammini, Sarah

Fondelli, Serena

Mencarini, Jessica

Vetrano, Umberto

Lambelet, Paola

Tagliaferri, Enrico

Menichetti, Francesco

Archivio della Ricerca - Università di Pisa

Acute varicella-zoster virus necrotizing meningoencephalomyelitis with sudden visual loss and paraparesis in an HIV-infected patient

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NEW MICROBIOLOGICA, 33, 267-269, 2010
Acute varicella-zoster virus necrotizing
meningoencephalomyelitis with sudden visual loss
and paraparesis in an HIV-infected patient
Carlo Tascini1, Marina Polidori1, Sarah Flammini1, Serena Fondelli1, Jessica Mencarini1, 
Umberto Vetrano1, Paola Lambelet2, Enrico Tagliaferri1, Francesco Menichetti1
1U.O. Malattie Infettive, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy;
2U.O. Medicina Generale, Ospedale Unico della Versilia, Camaiore Lucca
INTRODUCTION
VZV complications involving the CNS, such as
necrotizing meningoencephalomyelitis, are esti-
mated to occur in approximately 2% of patients
with AIDS (Kleinschmidt-DeMasters et al., 1998).
The prognosis is very poor, with a median sur-
vival of only 16 days (McKelvie, 2002). Therefore
aggressive empiric antiviral therapy should be
commenced as soon as VZV CNS infection is sus-
pected, based upon CNS analysis and the pres-
ence of skin blisters.
CASE PRESENTATION
A 55-year-old man was transferred to our hospi-
tal with a 7-day history of fever, headache and
Corresponding author
Carlo Tascini M.D.
U.O. Malattie Infettive 
Ospedale Cisanello
Azienda Ospedaliera Universitaria Pisana 
Via Paradisa, 2 - 56100 Pisa, Italy 
E-mail: c.tascini@ao-pisa.toscana.it
neck pain. On admission to the previous hospital,
a CT-scan and MRI of the brain with gadolinium
enhancement were both normal. Three days be-
fore admission to our hospital blindness suddenly
occurred in the left eye, followed after two days
by blindness in the right eye. The previous hos-
pital had treated him with dexamethasone and
ceftriaxone. On the day of transfer, an HIV-test
result was positive. 
On admission to our hospital the patient was
blind in both eyes and had lumbar pain. On phys-
ical examination there was no neck stiffness but
Lasègue sign was positive on both sides. There
was no motor deficit. Abdominal reflexes were
absent while tendon reflexes were normal. Finger-
nose test revealed dysmetria on the left side.
Sensory examination was normal.
Five skin blisters were noted on the right poste-
rior area of his chest.
Lumbar puncture revealed mild haemorrhagic
and xanthochromic CSF. The opening pressure
was 20 cm H2O, CSF protein concentration was
elevated (1096 mg/dL; normal range <40 mg/dL),
glucose level was normal (66 mg/dL). RBC count
was 750 cells/µl and WBC count was 80 cells/µl
We describe a case of acute varicella-zoster virus (VZV) hemorrhagic meningoencephalomyelitis in an HIV-infected
patient. On admission the patient’s CSF was mild haemorrhagic and xanthochromic after centrifugation and he had
thoracic skin blisters. VZV DNA was isolated from both the thoracic blisters and CSF. Treatment consisted of aggres-
sive antiviral, steroid and immunoglobulin therapy, which was able to stop disease progression. The patient survived
but was left blind and paretic. In conclusion, a diagnosis of CNS infection caused by VZV, based upon CSF analysis
and examination of the skin for typical blisters, requires aggressive empiric antiviral therapy in order to maximise pa-
tient survival.
KEY WORDS: VZV, Hemorrhagic meningoencephalomyelitis, HIV
SUMMARY
Received October 09, 2009 Accepted March 19, 2010
(72 lymphocytes and 8 polymorphs). Blood CD4+
T cell count was 3 cells/µl and HIV RNA level was
24,000 copies/ml. Treatment with 350 mg q12h
IV ganciclovir, 400 mg qd IV fluconazole and 6
MU q6h IV benzylpenicillin was administered
empirically. 
Two days after admission, CMV antigenemia was
positive (178 cells/200,000 cells), VZV DNA was
detected by PCR in the CSF and skin blisters,
while PCR for other herpes virus resulted nega-
tive. CSF HIV RNA levels were 1,330 copies/ml.
The same day flaccid paresis occurred and MRI
scan showed a diffuse meningeal enhancement,
with bilateral optic neuritis and chiasm inflam-
mation (Figure 1). 
Additionally, MRI scan revealed cervical and tho-
racic myelitis with hyperintense lesions in T2
weighted images of the anterior, posterior and
lateral white matter, with a “sugar-coating” pat-
tern (Figure 2). Therefore, 90 mg/kg q12h IV fos-
carnet was associated to ganciclovir, along with
high doses of steroids and IV immunoglobulin
30g for 3 and 5 days, respectively. Antiviral ther-
apy was administered for 28 days. By day 15, CSF
screened negative for VZV DNA. One week after
admission, antiretroviral therapy was started with
tenofovir, emtricitabine, ritonavir-boosted
lopinavir and enfuvirtide; after 10 days of thera-
py, CMV antigenemia was negative. The patient
survived but did not recover any lost visual or
neurological function, and he was transferred to
a rehabilitation unit. 
DISCUSSION
While VZV complications involving the CNS are
rare in patients with HIV/AIDS (Kleinschmidt-
DeMasters et al., 1998; Gray et al., 1994; Sotrel
1998), the poor prognosis dictates that an ag-
gressive antiviral treatment regimen is required,
which is the approach that we utilised in our pa-
tient. VZV infections of the CNS have been re-
ported in profoundly immunosupressed HIV-in-
fected individuals (Kleinschmidt-DeMasters et al.,
1998; Gray et al., 1994; Chretien et al., 1993) with
four variants recognised: multifocal encephalitis,
ventriculitis, focal necrotizing myelitis, and vas-
268 C. Tascini, M. Polidori, S. Flammini, S. Fondelli, J. Mencarini, U. Vetrano, P. Lambelet, E. Tagliaferri, F. Menichetti
FIGURE 1 - MRI of the patient’s brain: T2 sequence
demonstrated severe swelling of the optic nerves and chi-
asma.
FIGURE 2 -MRI
of the patient’s
spinal cord: T2
sequence demon-
strated severe
cord swelling.
culopathy leading to cerebral infarction (Gray et
al., 1994).
Compartmentalisation of VZV immunity in the
CNS may explain the profound CNS changes that
sometimes happen in the absence of systemic
symptoms, because the immune response is more
active in the CNS (Clark et al., 2004). For this rea-
son we also administered steroid and im-
munoglobulin therapy during antiretroviral ther-
apy, because vasculitis may be associated (Chang
et al., 2009). We were able to avoid death in our
patient, but permanent neurological defects were
irreversible due to necrotizing lesions caused by
VZV in the CNS. Necrotizing encephalomyelitis is
a devastating complication of VZV in AIDS, and
it is crucial to recognise this complication as ear-
ly as possible. The presence of xanthocromic CSF
and RBC in the CSF, suggestive of VZV infection,
along with associated skin blisters (Chang et al.,
2009), requires immediate aggressive empiric an-
tiviral therapy in order to treat this life-threaten-
ing condition. AIDS patients with a VZV CNS in-
fection treated with a combination of ganciclovir
and foscarnet or ganciclovir alone are reported
to have a significantly better final visual acuity
than those treated with either acyclovir or fos-
carnet (Moorthy et al., 1997).
Acknowledgements
Funding: Dr Tascini and Dr Menichetti received a
research and educational grant from Pfizer.
Competing interests: other authors, no conflict of
interest.
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VZV necrotising encephalomyelitis and HIV 269



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Acute varicella-zoster virus necrotizing meningoencephalomyelitis with sudden visual loss and paraparesis in an HIV-infected patient

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