Herpes zoster with meningitis in a vaccinated, immunocompetent child

Abstract

Herpes zoster with meningitis in a vaccinated, immunocompetent childDear Editor, Meningitis is a rare complication of herpes zoster (HZ) and its incidence was reported as only 0.5%. 1 Central nervous system complication most often occurs in immunocompromised patients or the elderly by infection with wild-type varicella zoster virus (VZV), although several cases have occasionally been reported with vaccine-strain VZV. 2,3 A healthy 7-year-old boy presented with a 3-day history of left facial, painful, pruritic skin rash and 1-day history of fever and vomiting. A review of his immunization record showed a varicella vaccination at 12 months of age, and that he had never had a varicella-like illness before. His vital signs were stable with tympanic temperature of 37.3°C. Skin examination detected tender, erythematous, swollen maculopatches and vesicles along the left V1/2 dermatome ( Fig. 1a). Laboratory studies showed normal levels of blood counts and serum chemistries. He was diagnosed with HZ, and i.v. acyclovir 10 mg/ kg every 8 h was started. The following day, he complained of posterior neck pain and physical examination showed positive nuchal rigidity and Brudzinski's sign. Spinal tapping was performed immediately and cerebrospinal fluid (CSF) contained lymphocytes and increased level of protein and glucose. Polymerase chain reaction (PCR) analysis of a CSF specimen was positive for VZV. Consequent immune evaluations were within normal limits. He was treated with an anti-meningitic dose of i.v. acyclovir (15 mg/kg every 8 h) for 8 days. His symptoms and skin lesions showed rapid improvement (Fig. 1b), and repeated PCR of CSF converted to negative on hospital day 10. He was discharged and was asymptomatic with a normal physical examination 3 weeks later (Fig. 1c). No pain or dysesthesia was reported.In Korea, a single-dose varicella vaccination for children between the ages of 12 and 15 months was incorporated into the national immunization program in 2005. Vaccination coverage was 92.9% in 2012, and a significant decrease in morbidity and mortality was achieved. 4 In addition, according to a recent population-based study, HZ incidence in vaccinated children was lower than in unvaccinated children and half of cases were due to vaccinated VZV. 5 Therefore, varicella vaccination is an advantage in many aspects but it contains a live attenuated virus with the potential for reactivation.Although it is unclear, there are hypotheses that certain timing and strain of vaccine may affect this process. Based on previous study implying that primary varicella infection in the first year of life is a risk factor for childhood zoster, Han et al. 2 suggested that early vaccination may put children at increasing risk for reactivation of the vaccine strain later in life. On the other hand, in recent studies on DNA sequencing of vaccinestrain VZV causing HZ meningitis, a vaccine strain from CSF contained mutations never previously observed in vaccineassociated single nucleotide polymorphisms that would alter amino acid sequences...

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

“…In all these cases any involvement of cerebral parenchyma was demonstrated and this supports one of unique feature of our case. To our knowledge, some cases of CNS infection due to reactivation of VZV in vaccinated children have been reported, but genotyping verification of the vaccine strain was available in a relatively small number of patients [16][17][18]. Regardless our patient, as the other two showed in the table, presented varicella during their infancy and they did not get vaccination.…”

Varicella Zoster Meningitis in an Immunocompetent Child

“…Past medical history was unre- or without rash. Zosteriform rashes had developed before any symptoms of meningitis in some patients, easily leading to the suspicion of VZV meningitis [5][6][7] . According to a recent retrospective study of 24 patients with meningitis and meningoencephalitis who showed typical zosteriform skin rashes, CSF tests and intra- Fig.…”