When infection mimics cauda equina syndrome: a cautionary tale

Area of Science:

• Neurology
• Infectious Diseases
• Neuroimmunology

Background:

• Cauda equina syndrome is a neurological emergency requiring prompt diagnosis and treatment.
• Varicella zoster virus (VZV) is a common virus that can cause various neurological complications.

Observation:

• A 63-year-old man presented with symptoms mimicking cauda equina syndrome, including low back pain, perineal numbness, and urinary retention.
• Cerebrospinal fluid analysis revealed a high lymphocyte count and positive VZV polymerase chain reaction, leading to a diagnosis of VZV myeloradiculitis (Elsberg syndrome).

Findings:

• Magnetic resonance imaging excluded spinal cord compression but showed brain hyperintensities.
• Despite treatment with intravenous aciclovir, the patient developed an intracerebral hemorrhage, likely due to VZV-associated vasculopathy.

Implications:

• Elsberg syndrome, caused by VZV, can present as a rare infectious mimic of cauda equina syndrome.
• This case underscores the potential for VZV to cause severe neurological complications, including vasculopathy and hemorrhage.
• Early recognition and treatment of VZV myeloradiculitis are crucial, although outcomes can be severe.