Case report Varicella zoster virus cerebral aneurysmal vasculopathy presenting in a newly-diagnosed HIV-positive patient Andrew Tomkins 1 , Chitra Babu 1 , Amit Herwadkar 2 , Rekha Siripurapu 2 and David McKee 3,4 Abstract We report the case of a newly-diagnosed HIV-positive patient with varicella zoster virus aneurysmal vasculopathy confirmed on intrathecal antibody testing, despite a negative Cerebrospinal fluid (CSF) Varicella Zoster Virus (VZV) Polymerase Chain Reaction (PCR). This highlights the importance of prompt treatment with antiviral and steroid therapy in the presence of clinical or radiological suspicion whilst awaiting further confirmatory testing. Keywords Antiviral, diagnosis, human immunodeficiency virus, varicella zoster virus, vasculopathy Date received: 5 April 2018; accepted: 11 June 2018 History A 38-year-old Zimbabwean woman attended the sexual health department for HIV testing. Her general practi- tioner had identified pancytopenia following investiga- tions which were requested due to a month-long history of general malaise and non-specific headaches. She had been a UK resident for the past 15 years, with her last negative HIV test being in 2004. She tested HIV- positive with a nadir CD4 cell count of 24 cells/mm 3 (4%) and a HIV viral load of 1,350,259 copies/ml (log 6.13). The following week, whilst attending her initial HIV appointment, she collapsed, having a witnessed 2- min tonic–clonic seizure. Investigations A CT brain scan and then a CT angiogram were per- formed, which showed multifocal aneurysms involving the both middle cerebral arteries. The patient under- went a contrast MRI brain scan and subsequent vessel wall imaging which demonstrated bilateral distal middle cerebral artery disease with localised dilatation and aneurysm formation. The posterior sylvian aneu- rysm on the right side demonstrated partial thrombosis and localised haemorrhage. Cerebrospinal fluid (CSF) testing demonstrated: protein 0.34 g/L, WBC <5 g/L, RBC 800, CSF glucose 2.7 (serum glucose 5.5), CSF HIV viral load of 140,882 copies/ml (log 5.15). Bacterial, fungal and viral (including varicella zoster virus [VZV]) CSF testing were negative. Intrathecal VZV antibody testing was requested, the results of which were available several weeks later therefore empirical treatment was commenced. This demonstrat- ed markedly increased CSF/serum ratio of anti-VZV IgG, demonstrating specific intrathecal synthesis of VZV antibodies (see Table 1). 1 The Hathersage Centre, The Northern Contraception, Sexual Health and HIV Service, Manchester University Foundation Trust, Manchester, UK 2 Department of Radiology, Salford Royal NHS Foundation Trust, Salford, UK 3 Department of Neurology, Salford Royal NHS Foundation Trust, Salford, UK 4 Department of Neurology, Manchester University Foundation Trust, Manchester, UK Corresponding author: Andrew Tomkins, The Hathersage Centre, The Northern Contraception, Sexual Health and HIV Service, 280 Upper Brook Street, Manchester M13 0FH, UK. Email: andrewtomkins@nhs.net International Journal of STD & AIDS 0(0) 1–3 ! The Author(s) 2018 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462418786334 journals.sagepub.com/home/std