Varicella zoster virus meningitis with hypoglycorrhachia in the absence of rash in an immunocompetent woman

Abstract

We report varicella-zoster virus (VZV) meningitis in a healthy adult woman with no antecedent rash and with hypoglycorrhachia. Cerebrospinal fluid (CSF) examination revealed the presence of VZV DNA, anti-VZV immunoglobulin G (IgG) antibody, and intrathecal production of anti-VZV IgG antibody.Keywords varicella zoster; meningitis; hypoglycorrhachia; PCR; immunocompetent Case reportA 26-year-old healthy Bhutanese woman developed increasing throbbing bitemporal headache with photophobia, severe nausea, and vomiting over 2 days. She had been afebrile and denied neck stiffness. There was no past history of headache, skin rash, recent insect bite, or contact with individuals with infections. She had chickenpox at age 5 years. She had emigrated from Bhutan 7 years earlier, but had not traveled abroad recently. Her sister had been treated for tuberculosis. She worked currently as a nanny; the children under her care were healthy and had received Varivax months earlier. On examination, the patient was afebrile and had no rash, nuchal rigidity, or abnormal neurological signs.On day 6 after becoming ill, white blood cell (WBC) count and routine blood chemistries, liver enzymes, erythrocyte sedimentation rate (ESR), anti-nuclear antibody, rapid plasma reagin, and human immunodeficiency virus testing were negative. Brain magnetic resonance imaging (MRI) revealed an ill-defined T2 hyperintensity in the right frontal lobe, extending from the cortical surface to the frontal horn of the lateral ventricle without mass effect, consistent with a hamartoma or cortical dysplasia. The cerebrospinal fluid (CSF) contained 331 WBCs, 99%

Varicella-zoster meningitis with a late-onset of skin eruption

“…Habib et al 6 reported herpes zoster meningitis with hypoglycorrhachia in an immunocompetent patient, similar to our case, except that in our case the patient had late-onset zoster rash. Primary infection of VZV causes varicella (chickenpox), after which the virus can remain latent in a cranial nerve or dorsal root ganglia at any point of the neural axis.…”

Varicella Zoster Virus Meningoencephalitis Presenting with Elsberg Syndrome without a Rash in an Immunocompetent Patient

“…Neither neck stiffness nor skin rashes were observed in our patient. The absence of neck stiffness is not uncommon in patients with VZV meningitis, whereas the onset of VZV infection without an apparent skin rash is unusual, although cases of VZV meningitis without rashes have been reported (11,12).…”

The Variegate Neurological Manifestations of Varicella Zoster Virus Infection

“…Like VZV vasculopathy, they also occur in the absence of zoster rash, as demonstrated by reports of VZV meningitis [9], meningoradiculitis [10], and cerebellitis [11], in which diagnosis was confirmed by the detection of VZV DNA or anti-VZV antibody or both in CSF.…”