Letters to the Editor 869 The MR of the brainstem showed a small A CURT of the herpes group. A strong signal was V DIETZ on ethidium ischaemic lesion in the left dorsolateral Swiss Paraplegic Centre, obtained bromide stained gel. medulla without any further pathology. University Hospital, Balgrist, Characterisation of HSV-2 DNA was Until confirmation of the total occlusion CH-8008 Zurich, achieved by restriction analysis of the of the left vertebral artery the patient was Switzerland amplified product. a-Interferon in CSF was treated with cumarine to prevent arterial Correspondence to: V Dietz, Paraplegic Centre, normal. The patient had no history of embolism. The clinical symptoms progres- Balgrist, Forchstrasse 340, CH-8008 Zurich, recurrent herpes genitalis. There was no sively disappeared over the next 30 days Switzerland. serological evidence for borreliosis, HIV-1 and the patient left hospital with only a 1 Hart RG. Vertebral artery dissection. or HIV-2, HTLV-I, Q-fever, listeriosis, slight ataxic gait and mild dysaesthesia Neurology 1988;38:987-9. cytomegalovirus, measles, varicella zoster, within the left C6 segment. 2 Fakhry SM, Jaques PF, Proctor HJ. Cervical or Epstein-Barr virus infection. CD4 counts vessel injury after blunt trauma. Jf Vasc Surg 1988;8:501-8. were normal and no cause for immuno- Discussion 3 Parent AD, Harkey HL, Touchstone DA, depression could be identified. The patient presented with an anterior dis- Smith EE, Smith RR. Lateral cervical spine Parenteral acyclovir (30 mg/kg daily) was placement and fracture of the left facet joint dislocation and vertebral artery injury. given for 10 days and the patient's neuro- Neurosurgery 1992;31:501-9. between level C5 and C6 and radicular pain 4 Louw JA, Mafoyane NA, Small B, Neser CP. logical state remained unchanged. Six days in the left C6 distribution, and subsequently Occlusion of the vertebral artery in cervical after admission, sparse vesicular lesions developed a left vertebral artery dissection spine dislocations. J Bone Joint Surg 1990; appeared on the patient's buttocks, internal with left brainstem ischaemia. It is 72B:679-81. suspect- 5 Jabre A. Subintimal dissection of the vertebral aspects of the thighs, and lower part of the ed that the dissection occurred during the artery in subluxation of the cervical spine. abdomen. Ten days later, numbness in both 19 day delay with subsequent occlusion Neurosurgery 1991;29:912-5. hands appeared. Examination showed bilat- including the posterior infracerebellar eral arm and shoulder weakness and the artery. By contrast with our case, most disappearance of upper limb reflexes. The reports during the past decade concerning patient then became confused and drowsy, posterior circulation ischaemia connected Herpes simplex virus type 2 ascending developed hyponatraemia and hyperazo- with vertebral artery occlusion occurred myeloradiculitis: 1IU findings and taemia and died on day 21 after admission. spontaneously or were loosely related to rapid diagnosis by the polymerase Necropsy examination was not performed. minor trauma during sport or neck manipu- chain method Subsequently, CSF cultures were reported lation during chiropraxy. These typically as positive for HSV-2. Analysis of serial occurred in young or middle aged adults, Although neurotropic viruses are often sus- serum samples showed a sevenfold rise in equally between the sexes.' Although trau- pected of causing spinal cord injuries, con- anti-HSV antibodies between admission matic fractures of the cervical spine occur firmation by early diagnosis is difficult. and death. IgM antibodies were detected in often, injuries of the vertebral arteries with Ascending myelitis related to herpes sim- one early serum sample. Analysis of the or without clinical symptoms are rarely evi- plex virus type 2 (HSV-2) infection has sel- CSF and serum anti-HSV antibodies ratio dent. The incidence is postulated to be dom been reported and the diagnosis could showed the existence of specific intrathecal between 3% and 10%.2 be established only at postmortem examina- synthesis. In a retrospective study Parent and tion. 1-5 We report the case of an elderly Various clinical syndromes have been coworkers reviewed some 640 patients sus- woman with a subacute ascending myelo- linked to HSV-2 involvement in the nervous taining fractures of the cervical spine. Of radiculitis. MRI showed spinal cord and system. HSV-2 encephalitis typically occurs these, 96 had facet involvement and in only sacral root involvement and the polymerase in the newborn, but accounts for less than five was injury of the vertebral artery diag- chain reaction allowed the rapid identifica- 5% of herpetic encephalitis in children and nosed by initial major neurological deficits tion of HSV-2 DNA in the CSF. adults. Acute, self limited meningitis is such as cerebellar infarction, cortical blind- A 76 year old woman was referred found in young adults with primary genital ness, or pontine infarction, which have been because of urinary retention and parapare- HSV infection. Sacral radiculitis with per- documented by postmortem examination in sis. Three weeks previously, she had noted ineal dysaesthesias, autonomic dysfunction, two cases.3 All these patients had cervical the progressive onset of anorexia, fever and sometimes mild lower limb weakness fractures located at C5-C6 and in one case (38°C), weight loss (4 kg), and low back may also be associated with herpes genitalis in combination with a fracture at C6-C7. pain. Evaluation performed in another hos- in young adults. In most cases, neurological Radiographs showed anterior dislocation at pital showed negative bacterial cultures symptoms occur two to seven days after the C5-C6 in four cases and at C6-C7 in one from blood and urine and CT of the thorax, genital eruption and patients recover within case. Bilateral facet fractures were evident abdomen, and lumbosacral spine was nor- three weeks. in four cases. mal. Three days before admission she com- By contrast, HSV-2 involvement in the Only one prospective study exists that plained of right sciatalgia and rapidly spinal cord is rare and severe. Two cases of considers the combination of facet joint dis- developed lower extremity weakness and HSV-2 extensive myeloradiculitis have been location of the cervical spine, the incidence sphincter disturbances. reported in patients with AIDS simultane- of vertebral artery injury, and the neurologi- Neurological examination showed a flac- ously infected with cytomegalovirus,' 2 and cal deficit.4 From 12 consecutively exam- cid paraplegia, a TI0 sensory level, and a two others in diabetic patients.34 HSV-2 ined patients with facet joint dislocation distended bladder. Deep tendon reflexes necrotising myelopathy has also been found (C5/C6 in seven, C6/C7 in three, and were absent in the lower limbs and plantar in association with malignancy.5 In all cases C4/C5 in two) nine showed an occlusion of responses were both extensor. In the upper the outcome was fatal within four to seven at least one vertebral artery. Of these nine extremities strength was normal but reflexes weeks, and the diagnosis could only be patients only two with bilateral facet joint were brisk and a bilateral Hoffman sign was made at necropsy, when HSV-2 was recov- dislocations had a transient neurological noted. Mental state and cranial nerves were ered from the spinal cord. There has been a deficit. Further indications of a traumatic or normal. single report of HSV-2 myelitis with a spontaneous dissection of the vertebral Non-enhanced TI weighted images of favourable outcome in which the virus was artery are neck pain and symptoms of a C6 the spine were normal. T2 weighted isolated from the CSF.6 root compression.5 sequences showed a linear hyperintense sig- In our patient, MRI clearly showed Thus a combination of neurological and nal at the T10 level and within the conus myeloradiculitis, on T2 weighted and radiological findings could lead to an early medullaris. TI weighted images with con- gadolinium enhanced TI weighted sagittal diagnosis and may indicate development of trast injection showed an enhancement of sequences. Although well correlated with a dissection of the vertebral artery. We sug- both the posterior meninges and the roots the clinical features, however, MRI findings gest that patients with the clinical symptoms of the cauda equina. lacked specificity. and type of injury described here are prone Her CSF contained 73 leucocytes/mm3 The direct diagnosis of nervous system to development of a dissection or occlusion (97% lymphocytes), 132 mg/dl protein and infection by HSV is difficult as isolation of of the vertebral artery. Early diagnostic pro- 68 mg/dl glucose. Electrophoresis of CSF the virus from CSF is most often unsuccess- cedures by non-invasive diagnostic tech- protein showed 26% y-globulins with an ful and serological confirmation is too late. niques such as MR angiography and oligoclonal distribution and a raised Recently, the polymerase chain reaction has ultrasound techniques coupled with treat- IgG/albumin ratio (0 56; normal <0 25). A proved to be a powerful tool in the rapid ment at the onset of a possible dissection polymerase chain reaction was performed diagnosis of meningoencephalitis due to may help to prevent the formation of a on CSF with a pair of primers that allowed herpes viruses. In this case, it allowed us to microembolism or arterial occlusion. the simultaneous detection of four viruses identify HSV-2 in the CSF immediately 870 Letters to the Editor after admission, a week before the appear- ism. An MRI showed a unilateral infarction nosis due to unilateral lesion. Although the ance of the cutaneous eruption. involving the left cerebral peduncle. precise anatomical basis for peduncular hal- The pathogenesis of HSV-2 myelitis in A previously healthy 70 year old right lucinosis remains unclear, it seems that the this case remains ill defined. Although IgM handed woman presented with visual hallu- substantia nigra pars reticulata (SNpr) is antibodies were detected in the first serum cinations.