Resolution of Recurrent VZV Myelitis With the Use of Intravenous (IV) Immunoglobulin (IG)

Abstract

Objective To present a case of a patient with recurrent VZV myelitis successfully treated with Intravenous Immunoglobulin (IVIG). Background VZV myelitis is a rare complication of VZV reactivation that tends to be monophasic. There is no solid evidence for a particular treatment regimen for VZV myelitis. No prior reports or studies have looked at using intravenous immunoglobulin for this condition, particularly for refractory cases. Design/Methods 75 year old female with history of hypertension presented with paresthesia on lateral side of right lower extremity, followed by vesicular rash T2 dermatomal distribution. Over a period of 2 weeks patient started experiencing bilateral lower extremity weakness R>L. CNS imaging revealed C3-C6 enhancing lesion and T2 hyperintense lesion. VZV confirmed by skin biopsy. Lumbar puncture (LP) was remarkable only for mildly elevated protein (67 mg/dL), although this LP was 4 weeks after initial symptoms. Patient was treated initially with 5 days of 1 g IV Solumedrol and valacyclovir 1 g TID with improvement of weakness and rash. However, over the next two years, the patient continued to get occasional vesicles with a flare of her myelitis shortly after valacyclovir down-titration trial. She was started on monthly IVIG (1 g/kg IVIG over 2 days) given her refractory and recurrent myelitis. Since starting monthly IVIG, the patient has not had any more zoster outbreaks or further episodes of myelitis. She has gradually improved her balance and gait as well. Results N/A. Conclusions We present an unusual case of recurrent VZV myelitis successfully treated with monthly IVIG. The successful treatment of this patient with IVIG should prompt consideration for its use in similar cases of recurrent VZV myelitis and may provide insight for future studies on how to treat VZV-related diseases. Rapid initiation of this treatment when the condition is recognized early could significantly improve outcomes and patients' quality of life.