Acute hemichorea in post-varicella vasculopathy

Chiara Davico,  Carlotta Canavese,  Aba Tocchet,  Chiara Brusa, Benedetto Vitiello.  Acute Hemichorea Can Be the Only Clinical Manifestation of Post-Varicella Vasculopathy: Two Pediatric Clinical Cases.  Front. Neurol., 20 March 2018 | https://doi.org/10.3389/fneur.2018.00164.

   

Acute hemichorea can occur in the context of infectious, autoimmune, metabolic, toxic, and vascular neuropathologies. Primary infection by varicella zoster virus (VZV) can result in vasculopathy with neurological manifestations, such as hemiparesis, at times accompanied by hemichorea. Isolated hemichorea, however, had not been reported. We here describe two cases of VZV-induced vasculopathy whose sole clinical manifestation was acute hemichorea. Both cases involved young boys of 3 years of age, who presented with acute hemichorea 4–6 months after initial VZV infection. All hematological, immunological, and toxicological tests were normal, except for the presence of VZV IgG. Brain structural magnetic resonance imaging (MRI) and magnetic resonance angiography revealed specific signs of vasculitis and ischemic lesions in the basal ganglia region (lentiform nucleus, thalamus, and internal capsule). Following corticosteroid and acetylsalicylic acid treatment, full symptomatic recovery was achieved within 3 weeks. Repeated MRI documented full neurostructural recovery, which was confirmed at extended follow-up for more than 1 year. These cases indicate that VZV-induced vasculopathy should be considered in the case of pediatric isolated acute hemichorea.

Case 1: (A) axial FLAIR image and (B) axial T2 weighted image, showing ischemic lesion involving the left      lentiform nucleus and posterior limb of the internal capsule. (C) Axial FLAIR image and (D) axial T2   weighted image showing resolution of the left lentiform nucleus lesion and reduction of the posterior limb involvement in the internal capsule. 

Case 2: (A) axial T1 image and (B) axial T2 weighted image, showing right thalamic nucleus and posterior limb of the internal capsule ischemic lesions. (C) Axial T2 weighted image and (D) axial T1 weighted image showing resolution of the right thalamic nucleus lesion and reduction of the involvement of the posterior limb of the internal capsule.

Case 2: Magnetic resonance angiography (MRA) showing reduced caliber of the right internal carotid artery, especially the supra-clinoid segment, and of the M1 segment of the middle cerebral artery, hypoplasia of the right A1 segment of the anterior cerebral artery, and tortuosity of the vertebrobasilar system.