A Diagnostic Approach to VZV Vasculopathy Using MR Vessel Wall Imaging

A 43-year-old woman with systemic lupus erythematosus on immunosuppressive therapy developed right hemiparesis and motor aphasia five months after the onset of herpes zoster. Brain magnetic resonance imaging revealed an infarction in the left anterior cerebral artery and severe middle cerebral artery (MCA) stenosis. Despite antiplatelet therapy, recurrent strokes occurred, and vessel wall imaging (VWI) showed circumferential thickening of the MCA, suggesting vasculitis. Cerebrospinal fluid revealed varicella-zoster virus (VZV) deoxyribonucleic acid (DNA) and an elevated anti-VZV IgG index, consistent with VZV vasculopathy. The administration of acyclovir and corticosteroids eliminated VZV DNA. This case highlights the risk of VZV vasculopathy in immunocompromised patients and the usefulness of VWI for its diagnosis.