Management of Post-Zoster Transverse Myelitis

Introduction to Treatment

The American Society of Clinical Oncology recommends immediate administration of high-dose intravenous acyclovir combined with high-dose corticosteroids, with temporary interruption of any immunosuppressive treatment until clinical resolution 1, 3

The Infectious Diseases Society of America suggests that high-dose intravenous acyclovir remains the treatment of choice for complicated VZV infections with transverse myelitis, and should be initiated immediately upon clinical suspicion 1
Intravenous acyclovir is preferred over oral formulations in cases of severe neurological complications like transverse myelitis 1
The duration of antiviral treatment should continue until complete resolution of symptoms 2

The American Society of Clinical Oncology recommends high-dose corticosteroids as the cornerstone of immunomodulatory treatment for transverse myelitis, with grading of treatment based on severity 3
For Grade 1 (mild) cases, methylprednisolone 2 mg/kg with permanent cessation of any immune checkpoint inhibitor is recommended 3
For Grade 2 (moderate) cases, consideration of higher doses of methylprednisolone and intravenous immunoglobulins (IVIG) is advised 3
For Grade 3-4 (severe) cases, methylprednisolone bolus 1 g IV daily for 3-5 days plus IVIG 2 g/kg over 5 days is recommended 3

The American Society of Clinical Oncology suggests that all immunosuppressive treatments should be temporarily interrupted until complete clinical resolution of the infection and neurological symptoms 2, 3

Essential diagnostic evaluation includes MRI of the spinal cord, lumbar puncture, blood tests, and immediate neurological consultation 3

The American Society of Clinical Oncology recommends antiviral prophylaxis with acyclovir or valacyclovir for all patients under immunosuppression after resolution of the acute episode 2