Varicella Zoster Meningitis in Immunocompetent Hosts: A Case Series
Stephanie Garza1, Ernesto Cavazos1, Carlos Gonzalez1
1Neurology, ITESM
Objective:
NA. 
Background:
The most common etiology of aseptic meningitis are viral pathogens. Varicella zoster meningitis (VZV) accounts for 2.5 - 8% of cases.
Design/Methods:
NA.
Results:

This case series describes 3 immunocompetent individuals with VZV meningitis associated with typical rash.

Case 1: A 26-year old man with a past medical history significant for primary varicella as an infant presented with headache, fever, photophobia, and painful vesicular rash over the back. Vital signs and neurological examination were within normal limits. The computed tomography (CT) scan of the brain was normal. Cerebrospinal fluid (CSF) analysis was suggestive of viral etiology with lymphocyte predominant pleocytosis. Polymerase chain reaction (PCR) analysis of CSF was positive for VZV. Intravenous (IV) acyclovir and supportive treatment were started. 

Case 2: A 36-year old man presented with headache, fever, myalgias and arthralgias. He recently traveled to Brazil but denies mosquito bites. Vital signs were normal, but Brudzinski’s and Jolt accentuation signs were positive.The magnetic resonance (MRI) of the brain did not show any enhancement. CSF analysis was suggestive of viral etiology. PCR analysis of CSF was negative for arboviruses but positive for VZV. A painful vesicular rash appears one day after admission. Treatment was started.

Case 3: A 49-year old woman with a past medical history significant for hypothyroidism present with a painful vesicular rash, headache, photophobia, myalgias and fever. Vital signs were normal. Nuchal rigidity was noted and the Jolt accentuation sign was positive. MRI of the brain has no findings. CSF analysis was suggestive of viral etiology and PCR analysis was positive for VZV. Treatment was started. 


Conclusions:
VZV meningitis incidence increases with age. Besides immunosuppression, other risk factors for reactivation include any condition that weakens cell-mediated immunity; treatment with lipid-lowering statins; and psychological stress. All three patients presented with headache as a pivotal symptom, and they improved with IV treatment.
10.1212/WNL.0000000000208256