Clinical spectrum and prognosis of neurological complications of reactivated varicella-zoster infection: the role of imm

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Clinical spectrum and prognosis of neurological complications of reactivated varicella-zoster infection: the role of immunosuppression Carlos Corral 1 & Carmen Quereda 2 & Alfonso Muriel 3 & Pedro-Luis Martínez-Ulloa 1 & Francisco-Javier González-Gómez 1 & Íñigo Corral 1 Received: 27 January 2020 / Revised: 8 June 2020 / Accepted: 15 June 2020 # Journal of NeuroVirology, Inc. 2020

Abstract Immunosuppressed patients are at higher risk for developing herpes zoster (HZ), and neurological complications are frequent in them. However, the influence of immunosuppression (IS) on the severity and prognosis of neurological complications of varicella-zoster virus (VZV) reactivation is unknown. We studied retrospectively patients with neurological complications due to VZV reactivation who attended our hospital between 2004 and 2019. We aimed to assess the clinical spectrum, potential prognostic factors, and the influence of the immune status on the severity of neurological symptoms. A total of 98 patients were included (40% had IS). Fifty-five patients (56%) had cranial neuropathies which included Ramsay-Hunt syndrome (36 patients) and cranial multineuritis (23 patients). Twenty-one patients developed encephalitis (21%). Other diagnosis included radiculopathies, meningitis, vasculitis, or myelitis (15, 10, 6, and 4 patients, respectively). Mortality was low (3%). At followup, 24% of patients had persistent symptoms although these were usually mild. IS was associated with severity (defined as a modified Rankin scale greater than 2) (odds ratio, 4.23; 95% confidence interval, 1.74–10.27), but not with prognosis. Shorter latency between HZ and neurologic symptoms was the only factor associated with an unfavorable course (death or sequelae) (odds ratio, 0.82; 95% confidence interval, 0.71–0.95). In conclusion, the clinical spectrum of neurological complications in VZV reactivation is wide. Mortality was low and sequelae were mild. The presence of IS may play a role on the severity of neurological symptoms, and a shorter time between HZ and the onset of neurological symptoms appears to be a negative prognostic factor. Keywords Varicella-zoster virus . Immunosuppression . Encephalitis . Cranial neuropathy . Meningitis . Prognosis

Introduction Varicella-zoster virus (VZV) reactivation, usually presenting as herpes zoster (HZ), is more frequent in older patients and patients with immunosuppression (IS) (Steinert et al. 2007; Schimpff et al. 1972). Neurological complications of this reactivation may involve both central and peripheral nervous systems, including cerebral parenchyma, brainstem, * Íñigo Corral [email protected] 1

Department of Neurology, University Hospital Ramón y Cajal, Madrid, Spain

2

Department of Infectious Diseases, University Hospital Ramón y Cajal, Madrid, Spain

3

Clinical Biostatistics Unit, University Hospital Ramón y Cajal and IRYCIS, CIBERESP, Madrid, Spain

cerebellum, spinal cord, cranial nerves, and nerve roots, as well as retina and arteries (Steinert and Benninger 2018). These complicat