Herpes zoster and Brown-Séquard syndrome

A 65-year-old immunocompetent woman presented with herpes zoster on the right breast, weakness of the right leg, and numbness of the left abdominal wall and leg. The patient history was otherwise unremarkable, and she took no medications. The clinical examination revealed a zoster typical vesicular rash at the right dermatome level of Th4 (Fig. 1a, b) and Brown-Séquard neurological syndrome with weakness of the right limb and dissociated sensory loss of the left abdominal wall and limb. The cerebrospinal fluid (CSF) examination revealed lymphocytic pleocytosis (102 cells/µl, normal <4 cells/µl) with marked elevation of CSF protein (1766 mg/l, normal <450 mg/l). The varicella zoster virus (VZV) antibody specificity index (IgG) was elevated to 2.6 (normal 0.6–1.2), and PCR test for VZV DNA in the CSF was positive (98,900 copies/ml, normal negative). Spinal magnetic resonance imaging (MRI) showed a hyperintense lesion of the right spinal cord at Th4 (Fig. 1c, d). Herpes zoster myelitis presenting with Brown-Séquard syndrome was diagnosed, and the patient was immediately treated with 750 mg of intravenous acyclovir every 8 h for 14 days. Strength was normal, and sensory impairment was nearly resolved 4 weeks after the onset of the disease.

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