Varicella Zoster Precipitating a case of Covid-19 Myelitis


 Covid-19 disease has plethora of clinical manifestations. There have been certain viral coinfection and presence of autoimmunity in Covid-19 disease. The predominant neurological manifestations of Covid-19 disease reported are encephalopathy, anosmia, headache, bell’s palsy, Guillain barre syndrome, acute transverse myelitis, acute demyelinating encephalomyelitis and strokes. In this illustration we presented an 11-year-old girl suffering from Covid-19 illness, presented with acute transverse myelitis along with Varicella-zoster co-infection substantiated by cerebrospinal fluid PCR positivity. There is a scarce literature of coexistence of varicella-zoster co-infection triggering myelitis in Covid-19 illness.


Case Description
The 11-year-old girl with cough and high-grade fever for six days, presented with acute-onset graduallyprogressive tingling sensation and numbness in lower limbs after three days of fever. Two days later, she felt weakness in both lower limbs(heaviness), initially proximally and then distally over 24 hours with urinary incontinence.
There is no history of headache, altered sensorium, seizures, blurred vision, diplopia, di culty chewing, speaking or swallowing. She had no signi cant past history. She was neither vaccinated to Covid-19 nor suffered from Covid-19 illness previously. Her general examination was normal. Nervous system examination showed normal mental functions and cranial nerve examination, including fundus. Motor examination revealed spastic lower limbs, symmetric 3/5 power, hypore exia and extensor plantars.
Sensory examination showed diminished pain, touch, temperature, vibration below T10-segment with intact joint position sensation. Rest of examination including gynaecological was unremarkable. Her laboratorical evaluation revealed normocytic-normochromic anemia, with normal leucocyte and platelet count, glucose, renal, liver, thyroid, electrolytes, vitamin B12 and D3 levels with negative serological tests for HIV, Hepatitis-B, Hepatitis-C with high titers of Covid-19 antibody (67.99 COI). CSF examination was normal with positive varicella-zoster PCR status, negative for Gram stain, fungal stain, CBNAAT, cryptococcal antigen, Japanese encephalitis, Ebstein barr virus, Entero virus, Herpes Simplex-1 virus, Covid-19 PCR. Her visual evoked potential (VEP) showed bilateral prolonged P-100 latencies, and limb nerve conduction study was normal. Her spinal imaging revealed longitudinally extensive transverse myelitis (LETM) in cervical spinal segment C4-C8 with normal brain and orbital imaging ( Figure-1). She was negative for NMO-MOG antibodies. She was treated with pulse methylprednisolone, acyclovir and supportive neuropathic drugs(pregabalin). She improved drastically and was discharged with power of 4+/5 in lower limbs, minimal sensory disturbance, and complete bladder recovery. At two months of follow-up, she had a Modi ed Rankin Scale of 1.

Conclusion
Covid-19 illness has plethora of immune-mediated manifestations. The diagnosis of Varicella-Zoster myelitis without rash is a challenge. Co-infection of Varicella-zoster can occur in Covid-19 disease.
Treatable causes of myelitis should be searched even in presence of Covid-19. The exact immunological mechanism of such involvement needs further exploration.

Declarations
Written, informed consent was taken from the patient/parents/legal guardians/next of kin for reporting this case.
The work has been approved by the appropriate ethical committees related to the institution(s) in which it was performed and that subjects gave informed consent to the work.
Con icts of interest: None Support or funding by any drug company: None There are no grants, honoraria, speaker's lists, signi cant ownership, and/or support from pharmaceutical or other companies such as manufactures of equipment, diagnostic or other laboratories whose products are directly or indirectly involved or affected by the article I as a principal author will take full responsibility for the data, the analyses and interpretation, and the conduct of the research; that I had full access to all of the data; and that I had the right to publish any and all data, separate and apart from the attitudes of the sponsor. Figure 1