We wish to thank Dr Barton for directing our attention to the
tabulation of varicella-zoster related stroke syndromes in children by
Moriuchi and Rodriguez.(Moriuchi H Rodriguez W Role of varicella-zoster
virus in stroke syndromes Pediatr Infect Dise J 20 19(7):648-53). In this
citation, there are two patients listed from another reference with
clinical presentations similar in time course to ours.
These two cases were identified by means of a survey given to parents
of children who experienced ischemic stroke, the "aim of which was to
explore functional outcome."(Ganesan V Kirkham FJ Mechanisms of ischaemic
stroke after chickenpox Arch Dis Child 1997 76:522-5). In the first of
these cases, a 3.5 year old boy became hemiparetic 1 week after varicella
onset, and was evaluated six months after his acute illness by MRA, which
showed a bilateral moyamoya pattern. No information about his clinical
course or assessment during the acute illness was offered. In the second
case, a six year old boy presented with seizures and homonymous hemianopia
a week after developing chickenpox. He had an initial deficiency of
protein S associated with elevated antivaricella serum IgM antibodies;
neuroimging by computed tomography showed an occipital infarction.
Neither patient was reported to have any vascular involvement outside
of the brain, in contrast to our patient with renal infarction and spinal
cord dysfunction.
An additional patient reported by Moros-Pena et al (Moros-Pena M et
al Cerebral ischemia following varicella Rev Neurol 2000 31(2):122-5)
presented with hemiparesis 8 days after varicella onset. This report from
July 2000 appeared after our case was submitted to Pediatrics, at about
the same time the article by Moriuchi appeared.
The documentation of systemic vasculitis involving blood vessels
outside the nervous system in an immunocompetent child with primary
varicella infection has not been submitted previously as we have stated.
Direct neurovascular imaging evidence of large blood vessel pathology in
this setting has not been submitted previously as we stated. Other
pathophysiologic mechanisms may have been at play in the the two cases to
which Dr Barton referred, and were excluded as potential causes in our
patient.
The rare complication of primary varicella vasculitis is life
threatening, and must be considered in any child who presents with altered
mental status or focal neurological deficits in the setting of an acute
varicella infection. We agree with Dr Barton that our case and others like
it highlight the need for universal varicella vaccination.
William Brown MD
Division of Pediatric Neurology
Hasbro Childrens Hospital/Brown University
Provience RI 02903
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