PMC9067377_01
The clinical course of the patient (schematic).
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F1
An outline of the episodes is described in Figure 1.
Cerebrospinal fluid (CSF) cytology shows atypical cells. (A) The atypical cells of CSF on day 5 after admission were scattered and varied in size, the cell membrane was malformed, and had a high nuclear-cytoplasmic ratio (black arrows). (B) The CSF cytology on day 19 after admission showed reactive lymphocytes and monocytes. Scale bars: 100 mum.
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F2
On day 5 after admission, the cytology testing of CSF revealed 4% lymphocytes, 2% monocytes, and 94% atypical cells (Figure 2A). Meanwhile, no atypical cells were found in the cytology testing of CSF (Figure 2B).
Serial neuroimaging with MRI demonstrating lesion amelioration. (A) Contrast-enhanced MRI brain (hospital day 5), (a,b,c) axial and (d) sagittal T1-weighted images showing diffuse leptomeningeal and pachymeningeal contrast enhancement (white arrows). (B) Repeat MRI on hospital day 29, (a,b,c) axial and (d) sagittal views showing less meningeal enhancement after 3 weeks of therapy. (C) Repeat MRI on the time of discharge (hospital day 62), (a,b,c) axial and (d) sagittal views showing the obvious resolution of the previous meningeal enhancement. (D) Repeat MRI on 6-month follow-up (a,b,c) axial and (d) sagittal views showing no meningeal enhancements. (E) MRI of the cervical and thoracic spine (hospital day 5), (a,c) sagittal T2-weighted and (b,d) post-contrast T1-weighted showing abnormal longitudinally extensive T2 weighted hyperintensities involving the C2-C3 and T6-T9. Partial enhancement was observed in the dorsal aspect of the spinal cord at C2 and T6-T7 levels (white arrows). (F) Repeat MRI on hospital day 29, (a,c) sagittal T2-weighted and (b,d) post-contrast T1-weighted images showing lesser abnormal hyperintensities compared with previously.
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F3
Brain MRI with contrast was reported as multiple abnormal signals in the cortex, extensive pachymeningeal enhancement, and irregular thickening (Figure 3A). Magnetic resonance venography and diffusion-weighted imaging were normal. MRI of the cervical and thoracic spine showed T2 hyperintense lesions located at C2-C3 and T6-T9, with partial enhancement (Figure 3E). A repeated MRI on day 29 after admission showed less meningeal enhancement (Figures 3B,F). A repeated brain MRI revealed obvious resolution of the previous abnormal pachymeningeal enhancement (Figure 3C). The repeated brain MRI revealed no abnormal meningeal enhancement (Figure 3D).
The metagenomic next-generation sequencing (mNGS) results of pathogen identification. Approximately 92.37% of viral reads corresponded to Human alphaherpesvirus 3 (also named the Varicella-zoster virus) with coverage of 99.6188% in CSF.
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F4
The sequencing detection identified 15,281 (out of 16,544) sequence reads uniquely aligned to the VZV genome, and these reads covered a high percentage (92.37%) of the VZV (Figure 4).