Rare Case of Epstein-Barr virus myelitis in immunocompetent individual: JAPI

India: A case published in the Journal of the Association of Physicians of India reports the rare occurrence of Epstein-Barr virus (EBV) myelitis in an immunocompetent individual. The case, in turn, is of a 13 years old boy who was presented with the symptoms of headache, malaise, sore throat and low back pain with radiation to both lower limbs.

EBV associated nervous system complications include encephalitis, meningitis, cerebellitis, polyradiculomyelitis, transverse myelitis, cranial and peripheral neuropathies, and psychiatric abnormalities are usually more commonly seen in immunocompromised patients and rarely in immunocompetent patients.

According to history, a 13 years old boy developed a headache, malaise, and sore throat. Over the next 2 weeks, he developed low back pain with radiation to both lower limbs initially right followed by left. Next day he felt numbness below umbilicus in the form of inability to feel clothes and touching with his own hands. A few hours later he developed acute onset weakness in both lower limbs in the form of inability to move his limbs in bed followed by difficulty in micturition leading to urinary retention. He required an indwelling catheter draining 800 ml urine on insertion. There was no history of fever, loss of consciousness, visual blurring, seizure, upper limb weakness, trauma or tuberculosis. There was no h/o fever, loss of consciousness, visual blurring, seizure, upper limb weakness, trauma or tuberculosis.

On neurological examination higher mental function, speech and cranial nerves including fundi were normal. The motor exam revealed proximal muscle power MRC grade 4/5 and distal power 1/5 in the right lower limb and proximal power 4-/5 and distal power 0/5 in left lower limb with normal power in both upper limbs. Biceps, triceps supinator, and knee-deep tendon reflexes were bilaterally normal while ankle reflexes were absent. Both plantars were mute. Other superficial reflexes were absent. All the modalities of sensation including pain, touch, temperature, joint position and vibration were impaired below the umbilicus. There were no meningeal or cerebellar signs. Examination of the spine revealed local tenderness without gibbus below L1 vertebral level and SLR test was positive bilaterally.

Routine investigations were normal. The magnetic resonance imaging (MRI) of thoracic spine showed intramedullary lesion in conus, which was iso-hyperintense on T1-weighted and hyperintense on T2- weighted images extending from D12thoracic vertebral level to L1 with cord expansion (Figures 1, 2). The MRI features were suggestive of conus myelitis. Cerebrospinal fluid (CSF) analysis revealed increased protein, normal cells, glucose, and Chloride. CSF Polymerase chain reaction (PCR) was positive for Epstein Barr virus.

The patient was treated with high dose intravenous methylprednisolone (1000 mg per day for 5 days) and antiviral drugs acyclovir 30mg/kg /day for 2 weeks. At the time of discharge, he showed moderate improvement in muscle power MRC grade 4/5 in both lower limbs with minimal left side foot drop during walking. He was discharged on supportive treatment and physiotherapy was advised.

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