A 61‐year‐old woman with a history of hypertension and neurofibromatosis type 2 with chronic occipital headaches, presented to the emergency department with a 3‐day course of frontal headache and a painful rash on her left flank. She described the headache as dull, different from her usual, 10/10 in intensity, worsened by sitting upright, unrelieved with NSAIDs, and associated with nausea, vomiting, photophobia and phonophobia. On admission, she was afebrile and had a blood pressure of 176/86 mm Hg. Examination revealed a vesicular rash with erythematous base from the left paravertebral area extending anteriorly following the left T6‐T7 dermatome. She was lethargic with poor attention span, but otherwise she had no other significant neurologic findings. Her blood tests were all within normal limits. MRI showed chronic findings related to neurofibromatosis type 2, including stable bilateral acoustic neuromas, mildly enlarging meningiomas involving the posterior falx and left anterior middle cranial fossa, and probable schwannoma or neurofibroma in the left Meckel's cave. CSF obtained through lumbar puncture revealed normal glucose, elevated protein and lactic acid, and leukocytosis (635/cu mm) with lymphocytosis (91%). CSF cultures were negative, but PCR was positive for varicella zoster and Epstein–Barr virus. The patient was given ganciclovir 2.5 mg/kg IV twice a day for 14 days, resulting in prompt resolution of symptoms.
Aseptic meningitis is a rare complication of herpes zoster reactivation. While subclinical meningeal irritation can occur in as much as 30%–40% of patients with shingles as manifested by CSF pleocytosis, only a rare few (0.5%–2.5%) develop full blown clinical aseptic meningitis. The underlying pathophysiology is unclear, particularly in immunocompetent patients. Symptoms may include high fever, severe headache, cervical rigidity, seizure, ataxia, hemiplegia, or even coma. These symptoms may occur within days after the appearance of the skin lesions. A high index of suspicion is important since some patients, such as in this case, may only complain of new onset headaches. CSF analysis is necessary for definitive diagnosis; PCR is widely used because of its speed and accuracy. Effective treatment requires intravenous administration of nucleoside analogues, such as acyclovir or ganciclovir, since oral regimens do not achieve sufficient drug levels. Patients usually recover fully without significant complications. While there are rare reports of varicella zoster meningitis in vaccinated patients, vaccination remains the most important strategy in the management of herpes zoster infections.
Aseptic meningitis should be considered in patients with shingles who develop acute neurologic symptoms. Prompt recognition leads to appropriate management with intravenous antiviral agents.
To cite this abstract:Patsias I, Paje D. Acute Aseptic Meningitis Associated with Herpes Zoster Reactivation in an Immunocompetent Adult. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 493. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/acute-aseptic-meningitis-associated-with-herpes-zoster-reactivation-in-an-immunocompetent-adult/. Accessed January 18, 2020.