?颅脑MRI-A显示：胼胝体区多发微出血
?颅脑MRI-B显示：双侧颞叶多发微出血
?左下肢弥漫性丘疹及血疱
?A33-year-oldhomelesswomanpresentedtotheemergencyroominSeptember,,with2daysofdrycough,dyspnoea,andfever,and1weekofpruriticrash.Onexaminationshehadatemperatureof41·0°C,bloodpressureof98/65mmHg,heartrateof85bpm,respiratoryrateof16bpm,andO2saturationof47%onroomair.
?Shehadadiffusepapularrashwithvesiclesofdifferentageswithhaemorrhagiccrustaffectingthetrunk,extremities,face,andscalp,butsparingthepalmsandsoles(figure).Shehadnormalmentalstatus,cranialnerves,motor,andsensoryexamination.Chestradiographshoweddiffusebilateralairspaceopacities.
?Withinafewhoursofpresentationshesuddenlybecameconfused,withflaccidparalysisnecessitatingintubationandadmissiontothemedicalintensivecareunit.Electroencephalogramshowednon-convulsivestatusepilepticus.MRIbrainshowedmultiplefociofpunctatemicrohaemorrhagesthroughoutthecorpuscallosum,bothtemporallobes,andleftposteriorcingulategyrus,consistentwithinfectioushaemorrhagicencephalitis(figure).HIVtestingwaspositive,withCD4count4cells/μL(normal–cells/μL),andviralloadwas66?copies/mL(normal50copies/mL).Askinbiopsysamplestainedpositiveforvaricellazostervirus(VZV),butnegativeforherpessimplexvirus(HSV).
?Zoster-associatedencephalitisfromdisseminatedVZVcandevelopwithindaysofthedisseminatedrash,andshouldbestronglysuspectedinimmunosuppressedpatients.Characteristicsignsofzoster-associatedencephalitisincludeacutedelirium,typicalsignsofstrokesuchasheadachewithacutehemiplegia,aphasia,ataxia,hemisensoryloss,orvisualchanges,dependentonthepredominantlocationoftheVZVvasculitis.Intravenousaciclovir10mg/kgevery8hfor7–10daysshouldbestartedearlyifthereisclinicalsuspicionofencephalitis.
?Ourpatientwasgivenintravenousaciclovirandmultipleantiepilepticdrugstocontrolherseizures.WetreatedherforVZVpneumonia,aspergilluspneumonia,propofol-inducedpancreatitis,Escherichiacoliurinarytractinfection,andcriticalillnessmyopathy.
?Afterstabilisationinhospitalshewasstartedonantiretroviralsandpneumocystispneumoniaprophylaxis.After2monthsofrehabilitationshecouldwalkindependentlyand鍖椾含娌荤枟鐧界櫆椋庣殑濂藉尰闄?鍖椾含涓尰闄㈣兘娌荤枟鐧界櫆椋?
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