When infection mimics cauda equina syndrome: a cautionary tale

A 63-year-old man presented to the emergency department with low back pain, perineal and genital numbness, together with bilateral lower limb paraesthesia and urinary retention. He was admitted under the orthopaedic service for investigation of suspected cauda equina syndrome. Magnetic resonance ima...

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Bibliographic Details
Published in:Annals of the Royal College of Surgeons of England 2021-06, Vol.103 (6), p.e181-e183
Main Authors: Shah, R, Jayakumar, N, Athar, S, Ashwood, N
Format: Article
Language:English
Subjects:
Blood tests
Cauda Equina Syndrome
Cauda Equina Syndrome - diagnosis
Central Nervous System Infections - complications
Central Nervous System Infections - diagnosis
Chicken pox
Diagnosis, Differential
Fatal Outcome
Genitalia, Male
Humans
Hydrocephalus
Hypesthesia - microbiology
Immunocompetence
Infections
Low Back Pain - microbiology
Lower Extremity
Magnetic resonance imaging
Male
Meningitis
Middle Aged
Nervous system
Neurology
Online Case Report
Paresthesia - microbiology
Perineum
Urinary Retention - microbiology
Varicella Zoster Virus Infection - complications
Varicella Zoster Virus Infection - diagnosis
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Summary:A 63-year-old man presented to the emergency department with low back pain, perineal and genital numbness, together with bilateral lower limb paraesthesia and urinary retention. He was admitted under the orthopaedic service for investigation of suspected cauda equina syndrome. Magnetic resonance imaging of his spine did not reveal any evidence of cauda equina compression. Magnetic resonance imaging of his brain demonstrated nonspecific multiple hyperintensities in the right frontotemporal and left temporo-occipital regions. Computed tomography of his chest, abdomen, and pelvis did not identify any evidence of malignancy. Cerebrospinal fluid from a lumbar puncture showed a high leucocyte count (predominantly lymphocytes). Viral cerebrospinal fluid polymerase chain reaction was positive for varicella zoster virus. A diagnosis of varicella zoster virus myeloradiculitis (Elsberg syndrome) was established and the patient was treated with intravenous aciclovir. Unfortunately, the patient succumbed to a devastating intracerebral haemorrhage during his inpatient stay, probably due to vasculopathy from the underlying varicella zoster virus infection. This case describes a rare infectious mimic of cauda equina syndrome. Elsberg syndrome is an infectious syndrome characterised by bilateral lumbosacral myeloradiculitis, with varicella zoster virus being a well-recognised aetiological agent. We discuss the relevant literature in detail and identify the key, cautionary lessons learned from this case.
ISSN:0035-8843
1478-7083
DOI:10.1308/rcsann.2020.7032