Could “the bloomy rind sign” be associated with meningeal dissemination of lung adenocarcinoma and varicella zoster virus infection? A case report and literature review

Background The bloomy rind sign, also described as a band-like lesion, is a characteristic imaging finding observed in a subset of patients with meningeal dissemination from lung adenocarcinoma (LA). However, its mechanism and clinical significance remain unclear. Methods We report a case in which LA with varicella-zoster virus (VZV) meningitis presented with a bloomy rind sign. A literature review was conducted to analyze the clinical and radiological characteristics of the reported cases. Results A 48-year-old man with stage IVB LA developed VZV meningitis and exhibited a characteristic lesion extending from the ventral pons to the cerebellar peduncles, showing hyperintensity on diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery, reduced apparent diffusion coefficient values, and no contrast enhancement. A review of 27 reported cases revealed highly consistent imaging findings, with DWI hyperintensity in all evaluated patients (26/26, 100%) and T2-weighted hyperintensity in all patients (27/27, 100%), whereas contrast enhancement was rare (1/26, 3.8%). The clinical outcomes were poor, with a mortality rate of 63.2%. Cerebrospinal fluid cytology was negative in 36.0% of the patients. The only nonneoplastic case presenting with the bloomy rind sign was associated with VZV meningitis, and VZV testing was performed in only 8.3% of LA-associated cases. The present patient was VZV positive. Conclusion The bloomy rind sign has consistent MRI features and may be a useful imaging marker for the early diagnosis of meningeal dissemination from LA. The present case raises the possibility that VZV infection may contribute to the development of the bloomy rind sign; however, this hypothesis is based on a single case and requires further validation.