Encephalitis due to herpes zoster without rash in an immunocompetent 12-year-old girl: case report and review of the literature

Abstract

Background: Neurological complications due to reactivation of varicella-zoster virus (VZV) are very uncommon in immunocompetent patients. Generally a vesicular rash is present on one or more dermatomes, preceding or following the main manifestation. Few cases are reported in the international literature, but they concern mainly adult or elderly patients. Case presentation: A 12-year-old girl was referred to our hospital for persisting headache, cough and rhinitis for six days. After first examination, diagnosis of anterior sinusitis was made by nasal endoscopy. The day after, the girl developed psychotic symptoms and altered mental status. Computed tomography (CT) scan was immediately performed but was unremarkable; lumbar puncture revealed leukocytosis with lymphocytic predominance and cerebrospinal fluid polymerase chain reaction (PCR) detected varicella-zoster virus DNA. The diagnosis of acute VZV encephalitis was made. The patient was promptly treated with acyclovir infused intravenously and her clinical conditions rapidly improved. Tests made did not show any condition of immunosuppression. Conclusions: Although if rare, reactivation of VZV can occur in immunocompetent children and its complications can involve central nervous system. Among these complications, meningitis is more common, but cerebral parenchyma can also be involved leading to a severe medical condition that is defined meningoencephalitis. In rare cases vesicular rash may be absent; therefore high level of suspicion is required even in those patients in which suggestive clinical features are not present to guide the diagnosis. Intravenous acyclovir represents the treatment of choice to obtain a fast clinical response and to prevent the onset of late-term complications.

Atypical Manifestation of VZV Infection in a Vaccinated Immunocompetent Adult

“…Given the poor bioavailability of oral acyclovir, intravenous (IV) acyclovir is the preferred route [3,11]. IV acyclovir ofers rapid clinical improvement in addition to reduction in long-term complications [12]. Gnoni et al reported a 29year-old immunocompetent patient with VZV meningitis that was successfully treated with IV acyclovir for 2 days followed by oral valacyclovir [13].…”

Meningitis due to Varicella-Zoster virus reactivation without rash in an immunocompetent adolescent

“…belongs to the Alphaherpesvirinae group, and causes infection exclusively in humans. 1,2 VZV primary infection (chickenpox) normally occurs in preschool or schoolaged children.1 After the primary infection, the virus remains latent in cranial nerves, dorsal roots, and autonomic ganglia, and it may reactivate years after the primary infection as zoster. 1,3 Both chickenpox and zoster may have neurologic complications, mainly in immunocompromised or older patients.…”

“…1,2 VZV primary infection (chickenpox) normally occurs in preschool or schoolaged children.1 After the primary infection, the virus remains latent in cranial nerves, dorsal roots, and autonomic ganglia, and it may reactivate years after the primary infection as zoster. 1,3 Both chickenpox and zoster may have neurologic complications, mainly in immunocompromised or older patients. 1,3,4 Reactivation is linked to a decline in cell-mediated immunity, and so, associated with immunocompromised or older individuals, being exceedingly rare in paediatric immunocompetent patients.…”

“…1,3 Both chickenpox and zoster may have neurologic complications, mainly in immunocompromised or older patients. 1,3,4 Reactivation is linked to a decline in cell-mediated immunity, and so, associated with immunocompromised or older individuals, being exceedingly rare in paediatric immunocompetent patients. 1,5 Pediatric reactivation cases seam to occur mainly when VZV-infection was acquired in the first year of life.…”

“…1,3,4 Reactivation is linked to a decline in cell-mediated immunity, and so, associated with immunocompromised or older individuals, being exceedingly rare in paediatric immunocompetent patients. 1,5 Pediatric reactivation cases seam to occur mainly when VZV-infection was acquired in the first year of life. 5 Investigations have suggested that children under one year may have immature or incomplete cellular immunity during the primary infection, failing to maintain virus latency later in life.…”