We describe a 59‐year‐old white man diagnosed with HIV for 16 years, noncompliant with antiretroviral therapy, who presented with combative behavior. Patient was complaining of fever, dry cough, and malaise for 2 days. Physical examination was unremarkable. Neurological examination was only pertinent for disorientation. Laboratory results showed CD4 count of 461 mm3 and HIV viral load < 75 copies/MI. Computed tomography (CT) of the brain showed low attenuation area in the brainstem and caudate nucleus. He was empirically started on intravenous (IV) ceftriaxone, vancomycin, acyclovir, and ampicillin for possible meningitis and encephalitis. He exhibited increased agitation and combativeness. Thus, he was transferred to the intensive care unit (ICU) for further evaluation. He was sedated and intubated. Magnetic resonance imaging (MRI) of the brain showed periventricular white matter ischemic changes. Pertinent cerebrospinal fluid (CSF) findings were predominance of lymphocytes, red blood cell of 30/mm3, elevated total protein (476 mg/dL) and normal glucose (54 mg/dL). Polymerase chain reaction (PCR) varicella zoster virus (VZV) was >2,000,000. HSV, enterovirus, RPR, VDRL and Cryptococcus Ag were negative. Acyclovir 700 mg IV every 8 hours was continued, the rest of the antibiotics were stopped. With continued clinical improvement, he was extubated after 4 days, transferred out of the ICU after 8 days and was finally discharged. After completing a 3‐week course of IV acyclovir he was noted to have remarkable improvement in his mental status.
Encephalitis is a rare complication of VZV infection with majority of cases reported in immunocompromised. This case illustrates VZV encephalitis in an HIV patient, which was promptly diagnosed and successfully treated. Our patient presented with VZV encephalitis with absence of skin lesions, which rarely occur in immunocompromised. Although no clinical trial has established the efficacy of antiviral therapy for VZV encephalitis, on the basis of case reports and small series, acyclovir 10‐15 mg/kg IV every 8h for 10‐14 days is the drug of choice. The efficacy has been proven in our patient as he showed remarkable clinical improvement after completing a 3‐week course of IV acyclovir.
Varicella zoster virus (VZV) encephalitis is a rare opportunistic infection with a high mortality occurring in 0.1 to 4% of HIV patients with neurological diseases. Early recognition, rapid diagnosis with CSF VZV PCR, and treatment with intravenous acyclovir are significant keys for a positive clinical outcome
To cite this abstract:Cirilo I, Cheriyath P. Blame It on the Virus. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 406. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/blame-it-on-the-virus/. Accessed April 2, 2020.