Varicella Zoster Virus Meningitis in a Young Immunocompetent Adult without Rash: A Misleading Clinical Presentation

Abstract

Meningitis caused by varicella zoster virus (VZV) is rare in healthy population. Predominantly immunocompromised patients are affected by reactivation of this virus with primary clinical features of rash and neurological symptoms. Here we report a young otherwise healthy man diagnosed with a VZV meningitis without rash. He complained of acute headache, nausea, and vomiting. The clinical examination did not show any neurological deficits or rash. Cerebrospinal fluid (CSF) analysis revealed a high leukocyte cell count of 1720 cells/µL and an elevated total protein of 1460 mg/L misleadingly indicating a bacterial infection. Further CSF analyses, including polymerase chain reaction (PCR) and detection of intrathecal synthesis of antibodies, showed a VZV infection. Clinical and CSF follow-up examinations proved the successful antiviral treatment. In conclusion, even young immunocompetent patients without rash might present with VZV meningitis. CSF examination is a key procedure in the diagnosis of CNS infections but in rare cases the standard values cell count and total protein might misleadingly indicate a bacterial infection. Thus, virological analyses should be considered even when a bacterial infection is suspected.

Varicella zoster virus meningitis under ustekinumab because of plaque psoriasis

“…These viruses persist within cranial nerves, dorsal roots and autonomic ganglia causing latent infections with the possibility of reactivation. 4 Acute infection or VZV reactivation affects predominantly older individuals and/or immunocompromised patients. VZV infection of the central nervous system (CNS) such as encephalitis, meningitis, myelitis or angiitis occurs less frequently but is feared because of the numerous unfavorable outcomes.…”

“…5 Usually, CNS infection with VZV comes along with dermal affection but can rarely develop without rash, like in our patient. 4 Acute infection or VZV reactivation affects predominantly older individuals and/or immunocompromised patients.…”

“…Ustekinumab, a monoclonal antibody that binds to the shared p40 subunit of interleukin (IL)-12 and IL-23, is approved in the USA, Europe and Eastern Asia including Japan for moderate to severe plaque psoriasis and psoriatic arthritis. 4,5 VZV infection involving the central nervous system, so far, has not been reported in patients during ustekinumab therapy. 2,3 Herpes simplex virus and varicella zoster virus (VZV) are common causes of meningitis and encephalitis in immunocompromised individuals but may also occur in immunocompetent patients.…”

“…2,3 Herpes simplex virus and varicella zoster virus (VZV) are common causes of meningitis and encephalitis in immunocompromised individuals but may also occur in immunocompetent patients. 4,5 VZV infection involving the central nervous system, so far, has not been reported in patients during ustekinumab therapy.…”

Varicella Zoster Meningitis in an Immunocompetent Child

“…VZV meningitis without rash has been reported in several studies and diagnosed by CSF PCR. In a recent epidemiological study of aseptic meningitis and encephalitis in adults, VZV was found in 5-29% 8,9) . In patients without clinical manifestations of VZV infection, diagnosis will be very difficult and delayed if CSF PCR is not performed.…”