Varicella Zoster Meningitis, Optic Neuritis Preceding the Development of Posterior Outer Retinal Necrosis, and Central Retinal Artery Occlusion in a HIV Patient

Abstract

Varicella-zoster virus (VZV) has been known to cause various eye disorders in both immunocompetent and immunocompromised patients. We present a case of a forty-nine-year-old female patient with acquired immunodeficiency syndrome (AIDS) who presented with headache, fever, and blurred vision. Cerebrospinal fluid (CSF) analysis was consistent with VZV meningitis. Magnetic resonance imaging (MRI) of the brain showed enhancement of the right optic nerve indicative of optic neuritis. She responded well to acyclovir and steroids and discharged on the same. Four weeks after discharge, she presented with sudden onset blindness in the left eye. A cerebral angiogram revealed left retinal artery occlusion and was treated with tissue plasminogen activator (tPA). Funduscopic examination showed patchy areas of necrosis in the periphery which were rapidly progressive, diagnostic of posterior outer retinal necrosis (PORN). She was started on ganciclovir and cidofovir and experienced significant improvement in her visual acuity.

Clinical manifestations of varicella zoster virus encephalitis in adults: A multifaceted presentation

“…VZV has been associated with cerebral artery disease, purpura outbreaks, and extensive thromboembolism, which are thought to be related to acquired antibody-mediated coagulation disorders [12,13]. However, reports of primary VZV infection causing CVST are rare.…”

Advances and Perspectives in the Management of Varicella-Zoster Virus Infections

“…VZV can be associated with severe acute retinal necrosis (ARN), a disease with poor prognosis; typically occurring in immunocompetent individuals though it can also occur in immunocompromised patients [ 16 , 17 ]. Unlike VZV necrotizing retinitis, progressive outer retinal necrosis (PORN), a form of VZV chorioretinitis, is found mostly in severely compromised people though, exceptionally, some cases of PORN have been described in immunocompetent persons [ 18 , 19 , 20 , 21 ]. Treatment strategies for PORN are rather unsuccessful and the disease can evolve fast leading to blindness within a few days or weeks.…”

“…Additionally, the frequency of VZV mutants was significantly higher following acyclovir pressure than penciclovir exposure [ 77 ]. As cidofovir (CDV, HPMPC) ( Table 2 ) is a nucleotide analogue that is converted to the active form CDVpp, by cellular kinases, it is a therapeutic option for therapy of ACV-R, PCV-R and/or PFA-R resistant VZV infections [ 21 , 78 , 79 ].…”