Asymptomatic varicella zoster virus infection presenting as Guillain-Barre Syndrome

Abstract

Guillain-Barre Syndrome (GBS) is a rare, serious, non-seasonal neurological disorder in which the immune system affects the peripheral nervous system, in most of the cases following a gastrointestinal or upper respiratory infection. Campylobacter jejuni, Mycoplasma pneumonia, CMV, EBV, or HIV infections have all been associated with GBS. Varicella zoster virus (VZV) is a rare cause of GBS. We are reporting a case of GBS following an asymptomatic VZV infection. A 64 year old male with history of hypertension presented with progressive limb weakness for 5 days. He had difficulty walking or lifting his hands. He had no history of respiratory, gastrointestinal or other infection for the past month. He was afebrile, without blisters or shingles on his trunk and neither had he exhibited them before. The neurological examination revealed absence of tendon reflexes and flexor plantar reflex bilaterally. The patient had weakness in upper and lower limbs (2/5). Sense of pinprick was impaired. Brain MRI scan showed chronic microvascular ischemic disease. Cervical/thoracic MRI scan was normal. Nerve conduction studies were compatible with acute inflammatory demyelinating polyneuropathy. CSF examination revealed elevated protein levels (96 mg/dL) and 5 cells/mm3 (albumino cytological dissociation). Laboratory tests including ESR, CRP, C3, C4 etc. were negative. PCR for CMV, EBV, HSV, Mycoplasma pneumonia, Legionella etc. on CSF was negative. CSF PCR for VZV was positive. VZV is the cause of chickenpox and herpes zoster and may be severe for immunocompromised patients. Usually, GBS follows the reactivation of VZV, but the pathogenesis is poorly understood.