Ischaemic stroke following VZ infection: a rare complication
The present case has been reported in BMJ. A previously healthy 28-year-old woman presented with generalised maculopapular lesions since 10 days which were associated with low-grade, intermittent fever. Six days following this, she developed double vision and swaying while walking. There was no history of headache, vomiting, seizure or limb weakness.

There was no significant medical history and neither she was on any drug therapy. On examination, she had generalised maculopapular rashes typical of varicella zoster virus (VZV) infection.

There was internuclear ophthalmoplegia with bilateral vertical nystagmus on upgaze. Other cranial nerves, and motor and sensory system examinations were normal. Cerebellar function tests like finger-nose test on right side and tandem walking test were impaired. The patient tends to sway on either side while walking.

MRI brain revealed an acute infarct in the right hemipons and superior cerebellar peduncle which could explain her neurological deficits. A complete diagnostic workup was conducted to identify the underlying cause of the stroke, which included cardiac echocardiography, bilateral carotid-vertebral Doppler, MRI angiography of cerebral vessels, antinuclear antibodies, antineutrophil cytoplasmic antibodies, antiphospholipid antibodies and HIV ELISA which were all negative. Lumbar puncture revealed normal pressure with no abnormalities in cerebrospinal fluid (CSF) studies. PCR for VZV was positive.

The patient was started on intravenous acyclovir, antiplatelet and other supportive therapy following which there was progressive improvement in her symptoms.

Learning points
• Varicella zoster virus (VZV) infection in adults could result in complications such as pneumonia and encephalitis, but presenting as stroke is very rare.

• Patients may present with acute or subacute infarction and commonly involves vessel being middle cerebral artery. Involvement of posterior circulation is very rare.

• The incidence of VZV vasculopathy is higher in immunocompromised individuals but may also occur in immunocompetent patients.

• A high index of clinical suspicion, efforts towards early diagnosis and initiation of acyclovir therapy are required to prevent complications.

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