Seronegative Epstein-Barr virus myeloradiculitis in an immunocompetent 72-year-old woman

Abstract

Epstein–Barr virus (EBV) infects more than 90% of humans and persists over the lifetime. The most frequent manifestation of acute EBV infection is mononucleosis; neurologic complications are less common. Serologic investigations are the mainstay of diagnosing acute EBV infection. However, we identified an immunocompetent 72-year-old woman with seronegative EBV myeloradiculitis. Within 1 week, a previously healthy 72-year-old woman developed flaccid paraparesis accompanied by sensory symptoms and bladder incontinence. She had scleral icterus but no fever. Liver enzymes and total bilirubin were elevated, erythrocyte sedimentation rate was 26 mm/hour, C-reactive protein was 15 mg/L (<5), and white cell count was 9,200 per mm3 (4,000 to 9,000). Differential count included 21% atypical lymphocytes. CSF contained 43 cells per mm3 and protein was mildly elevated. Spine MRI revealed gadolinium enhancement of the lower spinal cord and lumbosacral roots (figure, see page 1330). Cranial MRI was normal. Electrophysiologic studies could not detect F-waves in any lower limb nerve; instead, the right tibial nerve showed A-waves (see figure). We diagnosed myeloradiculitis and hepatitis of unknown cause and administered acyclovir, ceftriaxone, and ampicillin. Figure. Sagittal (A) and axial (B) views …