Reactivation of HSV-2 Leading to Elsberg Syndrome: A Case Report Highlighting Diagnostic and Management Challenges

Elsberg syndrome, or HSV-2 lumbosacral radiculitis, is a rare and underrecognized neurologic condition that mimics cauda equina syndrome (CES). It typically presents with symptoms such as urinary retention, saddle anesthesia, and bowel incontinence. This case report describes a 59-year-old immunosuppressed male with idiopathic pulmonary fibrosis who developed Elsberg syndrome due to re-activation of latent HSV-2. The patient experienced progressive lower extremity sensory deficits and genitourinary dysfunction, culminating in a vesiculopustular rash. Diagnosis was confirmed via cerebrospinal fluid analysis and PCR testing of skin lesions. Despite early imaging findings being unremarkable, subsequent MRI revealed enhancement of the conus medullaris and cauda equina. Treatment with intravenous acyclovir, corticosteroids, and supportive therapy led to gradual functional improvement, though sensory deficits and neuropathy persisted. This case highlights the diagnostic challenges and importance of clinical suspicion for HSV-2 reactivation in immunosuppressed patients, as well as considerations for long-term symptom management.