Herpes zoster as a cause of viral meningitis in immunocompetent patients

Abstract

A 30-year-old Caucasian woman, without significant medical history or immunosuppression, presented with a 7-day history of severe headache and neck pain. The patient was presumed to have tension headache versus migraine, but was admitted because her symptoms did not resolve. A lumbar puncture was performed showing lymphocytic pleocytosis suggestive of aseptic meningitis and the patient was started on broad-spectrum antibiotics and acyclovir. After admission, a rash was discovered on her left lumbar region with vesicles on top of an erythematous base. Varicella PCR was conducted on the patient's cerebrospinal fluid which was positive. Upon further history, patient was found to have previous varicella infection as a child, but no prior episodes of dermatomal zoster. Therefore, this patient was found to have aseptic meningitis and cutaneous manifestation of disseminated varicella-zoster despite immunocompetence. Antibacterial treatment was discontinued and she was continued on acyclovir for 7 days with transition to valacyclovir for 2 additional weeks with good treatment response and symptom resolution.

Herpes Zoster Infection Presenting as Aseptic Meningitis and Dermatomal Rash in Immunocompetent Adult

“…Aseptic meningitis prior to vesicular eruption was notable presentation in our patient as Takeshima et al reported only two of 11 cases had herpes zoster meningitis prior to the dermatological lesion [4]. Similar to our case, herpes zoster aseptic meningitis preceding dermatological rash was reported by Kangath et al [5].…”

“…However, our patient was a young adult with herpes zoster infection presenting as aseptic meningitis and dermatomal rash that make his presentation unique. A similar case report of herpes zoster in the young adult was reported by Kangath et al [5]. Most of the patients with herpes zoster commonly occurred in the immunocompromised people as reviewed by the Bollea-Garlatti et al [6]; however, our patient had negative workup for immunocompromised status.…”

“…e patient had an excellent response to the treatment. Similarly, Kangath et al reported that the patient with disseminated herpes had a good response with IV acyclovir 500 mg three times a day for seven days and transition to valacyclovir for two additional weeks [5]. We did not prescribe valacyclovir due to its unavailability in the local market.…”

Varicella zoster meningitis: an atypical case of zoster reactivation in immunocompetent young adult

“…It is underdiagnosed due to the lack of availability of PCR and intrathecal testing of varicella zoster virus compared with herpes simplex virus (HSV) testing which is readily available in healthcare facilities. 4 Because of its low incidence, atypical presentation and unavailability of testing, diagnosis requires high index of suspicion. Isolated neurological symptoms presenting without dermatomal rash can be easily be missed once HSV meningitis is ruled out and can result in premature cessation of antivirals.…”

“…Cases have been reported where meningitis has present solely with rash without preherpetic or postherpetic neuralgia as occurred in our case. 4 If dermatomal pain is the only finding, it is known as zoster sine herpete (ZSH).…”