Encephalitis Following Herpes Zoster Ophthalmicus

Abstract

85-year-old female had been hospitalized for a diagnosis of herpes zoster in the Dermatology Department 10 days ago due to redness and vesicular lesions on the left eyelids and the left side of the forehead, and had been started IV acyclovir 500 mg tid. She was consulted with us because of development of diplopia, agitation, and disorientation one day later. She was unconscious, and had partly encrusted vesicular lesions on a hyperemic ground extending to frontotemporal area and involving the left eyelids on her left side of the forehead. She was transferred to our clinic with the prediagnosis of herpes zoster ophthalmicus and varicella zoster virus (VZV) encephalitis, and the acyclovir dose was escalated to 750 mg tid. There were 150/mm 3 leukocytes (90% lymphocytes) and abundant erythrocytes on cerebrospinal fluid (CSF) microscopy. Biochemical analysis of CSF revealed concentrations of protein of 2149 mg/dL, glucose of 37 mg/dL and simultaneous blood glucose of 72 mg/dL. Gram and Ehrlich-Ziehl-Neelsen stained smears showed no microorganism. Both CSF and blood cultures yielded no growth. Polymerase chain reaction (PCR) for Mycobacterium tuberculosis and Brucella standard tube agglutination were negative. In cranial magnetic resonance imaging (MRI), there were bilateral periventricular diffuse, on FLAIR sequences, hyperintense nodular white matter signal abnormalities, deepening of cortical sulci and fissures, a subdural collection (14 mm in thickness) in bilateral frontal areas, and hyperintense abnormalities (5 mm in thickness) suggesting acute-subacute haemorrhage on the right in T1-weighted images. In diffusion MRI, there was no restricted diffusion compatible with cytotoxic edema in brainstem, cerebellum and both cerebral hemispheres. The collection was attributed to cortical atrophy, and an antiedema treatment was recommended in neurosurgical consultation. Dexamethasone 4 mg qid was started, and administered for 6 days by cutting half the dosage every other day. The patient got better beginning from 7 th day of the antiviral therapy. Her consciousness, cooperation and orientation improved, and her skin lesions decreased. VZV DNA was found positive by PCR in CSF. Her therapy was completed on 21 st day, and she was discharged from the hospital with full recovery.

Herpes Zoster Burden of Disease and Clinical Management in Turkey: A Comprehensive Literature Review

“…Overall, while there was an absence of comprehensive, nationwide data on HZ incidence in Turkey, 39 case reports or series, detailing numerous HZ-related complications and accompanying treatment strategies, were identified ([ 56 – 94 ]; Supplementary Table 1). Among these case studies, HZ ophthalmicus (HZO), characterized by the reactivation of VZV in the ophthalmic nerve, affecting regions around the eye, was the most common complication described (12 out of 43 patients described) [ 60 , 62 , 64 , 66 , 70 , 72 , 76 , 79 , 80 , 89 , 91 , 92 ]. Other reported HZ-related complications included PHN, Ramsay Hunt syndrome, segmental zoster paresis, VZV encephalitis, orbital apex syndrome, Ogilvie’s, complex regional pain syndrome, Horner’s syndrome, polymyalgia rheumatica, and brachial plexopathy, among others (Supplemental Table 1).…”