An 80-year-old man with a history of renal transplant, on tacrolimus and prednisone, presented with confusion and fever (38.3°C). Brain MRI demonstrated leptomeningeal enhancement, and lumbar puncture revealed a mixed pleocytosis with 533 white blood cells/μL (45% lymphocytes) and 950 red blood cells/μL. Varicella zoster was identified in the CSF by PCR. He exhibited diffuse hyperreflexia and clonus at the bilateral finger and wrist flexors within 72 hours of admission (video, links.lww.com/WNL/A323). Spasticity and clonus are pathologic upper motor neuron signs that can be observed early in the course of meningoencephalitis1 and other acute neurologic disorders.2
Author contributions
James E. Siegler: preparation of manuscript, study supervision. Xin Zhou: acquisition of data, critical revision of manuscript for important intellectual content.
Study funding
No targeted funding reported.
Disclosure
The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Footnotes
Teaching slides: links.lww.com/WNL/A324
- © 2018 American Academy of Neurology
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