There are several previous reports that infection or reactivation of varicella zoster virus (VZV) can occur after coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Herein, we report a rare case of VZV meningitis in breakthrough COVID-19. An 18-years-old male visited the emergency room, presenting with a headache and fever of up to 38.4°C for 5 days. He received the second dose of BNT162b2 mRNA SARS-CoV-2 vaccine 7 weeks prior to symptom onset. The symptoms persisted with headache, fever, and nausea. His cerebrospinal fluid (CSF) showed an elevated opening pressure of 27 cm H 2 O, 6/µL red blood cells, 234/µL white blood cells (polymorphonuclear leukocytes 3%, lymphocytes 83%, and other 14%), 43.9 mg/dL protein, and 59 mg/dL glucose, and CSF polymerase chain reaction (PCR) test was positive for VZV. Also, he was diagnosed with COVID-19 by reverse transcriptase-PCR examining upper and lower respiratory tract. We administered intravenous acyclovir for 12 days, and he was discharged without any neurologic complication.

Background:In patients with transient ischemic attack (TIA), acute infarction was often found on diffusion-weighted magnetic resonance imaging. Infarcts associated with TIA typically have small lesion size, but it is unclear whether the lesion characteristics of TIA-related infarcts can be distinguished from those of lacunar stroke. Methods: Twenty-three patients with TIA with subcortical infarction (TSI) and 47 patients with lacunar stroke with subcortical infarction (LS) were analyzed. The size and relative location of infarcts in the corona radiata (CR) were compared between the two groups on diffusion-weighted imaging.Results: The location of LS was limited to the posterior portion (3/5) of the CR, whereas the location of TSI was distributed over the whole portion of the CR. While the lesion size of TSI located in the anterior half of the CR was similar to that of LS (63.5±16.3 mm 2 vs. 63.9±33.1 mm 2 , p=0.96), the lesion size of TSI in the posterior half of the CR was smaller than that of LS (17.4±5.8 mm 2 vs. 63.9±33.1 mm 2 , p<0.01). Conclusions:The results suggest that the lesion characteristics of TSI include noneloquent location in the anterior CR or very small (smaller than lacunar stroke) lesion size in the eloquent location of the posterior CR. TIA with subcortical infarction may be a distinct syndrome in clinical manifestations as well as in lesion characteristics distinguished from lacunar stroke.