# Varicella zoster virus meningoencephalitis and vasculopathy in an immunocompromised patient with rheumatoid arthritis: a diagnostic challenge

## TL;DR

This paper discusses a complex case of Varicella Zoster Virus (VZV) infection in a patient with rheumatoid arthritis, highlighting the importance of specific diagnostic tools for accurate diagnosis.

## Contribution

The paper emphasizes the diagnostic value of intrathecal VZV-IgG antibody production and the Antibody Index in VZV vasculopathy.

## Key findings

- Intrathecal VZV-IgG antibody production and Antibody Index are crucial for diagnosing VZV vasculopathy.
- The case highlights the diagnostic challenge between VZV infection and rheumatoid arthritis vasculopathy.
- Prompt diagnosis is essential for effective treatment of CNS complications in immunocompromised patients.

## Abstract

The purpose of this paper is to describe a challenging case of a Varicella Zoster Virus (VZV) meningoencephalitis-vasculopathy in an immunocompromised patient with severe Rheumatoid Arthritis (RA), emphasizing on diagnostic tools. Hereby, we present an elderly immunocompromised patient with RA that developed meningoencephalitis and Central Nervous System (CNS) vasculitis, only two months after discontinuation of her RA medication due to a VZV rash. The clinical, imaging and laboratory investigation that was performed led to a diagnostic dilemma, as it could argue in favor both of VZV infection and RA activation in CNS. The intrathecal production of VZV-IgG antibodies and “Antibody Index” are fundamental tools in the diagnosis of VZV vasculopathy, rather than the presence of virus in CNS itself. Based on this finding in our patient and taking into consideration that RA vasculopathy is rarer, the patient was treated with acyclovir and methylprednisolone as indicated for VZV meningoencephalitis-vasculopathy. Since the therapeutic approach of CNS complications in immunocompromised patients is an additional challenge, the correct diagnosis becomes even more necessary. This article highlights the diagnostic tools that can assist neurologists making the correct diagnosis promptly, even when biopsy is not possible or undesirable.

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