Varicella Zoster Virus VZV vasculopathy

Diagnosis:

Clinical: large artery or small vessel ischemic stroke, recurrent, protracted course. Rash may be absent or occur months before
MRI, CT: large artery or small vessel ischemic stroke, typically at grey-white junction. Imaging is sensitive but not specific
Anti-VZV IgG & VZV PCR: IgG is more sensitive for VZV vasculopathy, also reduced serum/CSF ratio of VZV IgG
CSF: pleocytosis occurs but isn’t sensitive,

Pathology:

  • Multinucleated giant cells, lymphocytes & histiocytes in the artery walls
  • Avidin-biotin-peroxidase staining: VZV antigen staining in Cowdry A inclusions (large with halo) in cytoplasm of histiocytes in the artery walls
  • Immunohistochemistry: Anti-VZV Ig, stains positive in the arterial wall
  • EM: viral particles

Treatment:

  • Acyclovir for 3 weeks

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