Varicella Zoster aseptic meningitis: Report of an atypical case in an immunocompetent patient treated with oral valacyclovir

Abstract

Varicella Zoster when described has the typical presentation of a dermatomal distribution of a rash and can further lead to CNS complications. This can be treated accordingly with the proper protocol, but if the presentation is atypical and the protocol is challenged or changed per specific patient outcomes, new developments can occur. Here we present a case of a 29-year-old Caucasian female that presented to the emergency department with headache, photophobia, and chills for 5 days. She was previously healthy and immunocompetent; CSF PCR analysis revealed a VZV infection causing acute aseptic meningitis with no shingles rash eruption on physical examination. The patient was not willing to stay hospitalized for the duration of the treatment. This gave us an opportunity to treat her with an oral, rather than IV, antiviral. The patient was successfully treated with oral valacyclovir 2 g Q6H after only receiving two days of IV acyclovir. To the best of our knowledge, this is the first reported case of a patient with VZV-associated meningitis successfully treated with oral valacyclovir.

Concurrent maxillary herpes zoster, meningitis, focal cerebral arteriopathy, and ischemic stroke: A case report

“…The persistent and aggravating headache of our patient was disproportionate despite her antecedent flu‐like episodes. Positive meningeal signs, CSF pleocytosis and widespread enhancement of tentorium and cerebelli pia mater on contrast MRI supported a diagnosis of meningitis, in accordance with the reported aseptic meningitis caused by VZV in immunocompetent individuals 7‐9 . The subtle abnormality, that is, slightly asymmetrical tendon reflexes of limbs, and positive Babinski's sign on the left side were atypical and could be explained by the acute combined right‐sided cortical and internal watershed infarction shown on DWI.…”

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

“…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. Only a few cases with herpes zoster presenting as aseptic meningitis in immunocompetent were reported in the medical literature [7]. 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].…”

Varicella-zoster meningitis in an immunocompetent young man presenting with a painless erythematous rash

“…Moreover, the optimal treatment for VZV meningitis remains ill-defined and global guidelines are yet to be established 16. Most clinicians tend to favour intravenous acyclovir for a period of 10–14 days, although oral valacyclovir has also been reported to be efficacious 17. Although enterovirus and HSV are by far the most common causes of aseptic meningitis and largely self-limiting with supportive care, definitive clinical diagnosis is not always possible 16.…”