A case of acute sensory neuropathy associated with cytomegalovirus infection

We report a non-compromised patient with acute sensory neuropathy (ASN) developed following cytomegalovirus (CMV) hepatitis. A 67-year-old man admitted to a hospital because of acute hepatic dysfunction accompanying fever and skin eruption. One month later, when hepatic function normalized, numbness and clumsiness started acutely first in the right upper limb next to all the extremities. He found difficulty in walking in a couple of weeks. One month after the commencement of neurological illness, he was referred to us. On examination, he had sensory limb ataxia. His gait was wide-based, and Romberg sign was positive. Position sense was severely diminished in the extremities. Skin sensation was also attenuated distally, while no motor weakness was noted. Tendon reflexes were almost absent. Nerve conduction studies revealed absent sensory potentials in all but the left median nerve, in which amplitude was 5.5 microV with sensory conduction velocity of 40.7 m/s. Motor conduction studies, on the other hand, appeared normal except for a slight focal delay in the right ulnar nerve across the elbow. Mild increase in F-wave latencies was noted. A sural nerve specimen taken two months after the neurological onset showed a marked decrease in myelinated fiber density and active fiber degenerations accompanying axonal sproutings. Sjogren syndrome and paraneoplastic neuropathy were excluded serologically and by comprehensive imaging techniques. Although IgM anti-CMV antibody was not detected, serum IgG anti-CMV antibody was positive and significantly increased during the neurological illness. The intrathecal antibody synthesis of IgG anti-CMV antibody was suggested by a low serum/cerebrospinal fluid (CSF) antibody ratio and a high CSF IgG index. From these observations, it was strongly suggested that acute hepatitis and subsequent ASN were associated with CMV infection in this patient. Although some cases with post-infectious ASN have been previously reported, this is the first report of ASN preceded by CMV infection.