Two Cases of Varicella Zoster Virus Meningitis without Fever and Rash: An Unexpected Clinical Presentation

Abstract

Aseptic meningitis caused by Varicella-Zoster virus (VZV) is a rare phenomenon in the healthy population. Immunocompromised patients are predominantly affected by viral reactivation, characterized by rash and neurological symptoms, and meningitis as a rare complication. Herein, we report two cases of VZV meningitis in adult patients without rash and fever over a 4-month period. The first case was an immunocompetent 37-year-old male who presented with persistent headache, agitation and unclear speech. The second case was an immunocompromised 76-year-old male who was admitted to the emergency department with confusion, disorientation, dizziness, loss of consciousness, pain in the lower left extremities and difficulty in walking. Cerebrospinal fluid (CSF) analysis in both patients revealed a high leukocyte cell count with 97% lymphocytes. CSF gram staining and culture were negative. CSF polymerase chain reaction (PCR) analysis indicated VZV infection. Both patients were administered acyclovir for 14 days and were discharged without any neurological sequela. This case report series highlight the presentation of VZV as aseptic meningitis in both immunocompetent and immunocompromised patients without the typical clinical symptoms and should always be considered by the clinicians.

Keywords

• Varicella-Zoster virus
• meningitis
• cerebrospinal fluid
• rapid diagnosis
• PCR

References

1. Meng Q, Wang B, Zhang X, et al. Case Report: Various Clinical Manifestations Caused by Varicella-Zoster Virus in a Family. Front Pediatr. 2022; 10:876250.
2. Sahra S, Jahangir A, Glaser A, et al. Case report: aseptic meningitis secondary to varicella-zoster virus (VZV) without an exanthem post MMR vaccination. BMC Infect Dis. 2021; 21(1):746.
3. Pasedag T, Weissenborn K, Wurster U, et al. Varicella Zoster Virus Meningitis in a Young Immunocompetent Adult without Rash: A Misleading Clinical Presentation. Case Rep Neurol. Med 2014; 2014:686218
4. Andrei G, Snoeck R. Advances and Perspectives in the Management of Varicella-Zoster Virus Infections. Molecules. 2021; 26(4):1132.
5. Gaudin M, Theis C, Mrozek N, et al. Varicella zoster virus and meningitis in immunocompetent patients: Specificity and questions. Clin Infect Pract. 2022; 100125.
6. Raziq FI. Varicella Zoster Virus Causing Aseptic Meningitis Without Fever or Rash in an Immunocompetent Patient. Am J Infect Dis. 2020;16(2):55-59.
7. Khaliq MF, Kochar T, John M. Varicella zoster meningitis: an atypical case of zoster reactivation in immunocompetent young adult. BMJ Case Rep. 2018; bcr2017223257.
8. Yasuda R, Minami K, Ogawa A, et al. Herpes zoster and meningitis in an immunocompetent child: a case report. J Med Case Rep. 2019;13(1):182.

9. Leahy TR, Webb DWM, Hoey H, Butler KM. Varicella Zoster Virus Associated Acute Aseptic Meningitis without Exanthem in An Immunocompetent 14-year-old boy. Pediatr Infect Dis J. 2008;(4):362-3.
10. Echevarria JM, Casas I, Tenorio A, et al. Detection of varicella-zoster virus-specific DNA sequences in cerebrospinal fluid from patients with acute aseptic meningitis and no cutaneous lesions. J Med Virol. 1994; 43(4):331–5.