SHM Converge Scientific Abstract ePoster Gallery-A Case of Varicella Zoster Meningoencephalitis

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An 83-year-old man with poorly controlled type 2 diabetes (A1c 10.9%) and a history of recurrent varicella zoster virus (VZV) infections presented with three days of worsening unilateral facial pain, vesicular rash, headache, and nausea. He had received the live zoster vaccine (Zostavax) three years earlier. Exam showed a right-sided vesicular rash in the V1 cranial nerve distribution, consistent with herpes zoster ophthalmicus. He was admitted and started on intravenous acyclovir.<br /><br />Lumbar puncture showed inflammatory cerebrospinal fluid with lymphocytic pleocytosis, elevated protein, and positive VZV PCR, confirming VZV meningoencephalitis. Although the rash improved, his pain and headaches persisted. He completed two weeks of inpatient acyclovir and was discharged on pregabalin for severe post-herpetic neuralgia. Over the next two months, he was readmitted three times for complications including neuralgia, delirium, and meningoencephalitis.<br /><br />This case highlights that VZV is an under-recognized cause of viral meningoencephalitis and may be more common than herpes simplex virus encephalitis, yet it is tested for less often. In patients with herpes zoster ophthalmicus, especially those with persistent neurologic symptoms or other risk factors, clinicians should have a low threshold for lumbar puncture and CSF testing. The case also emphasizes that uncontrolled diabetes may act as an important immunocompromising condition and likely contributed to disease progression. Prevention is important: Shingrix is significantly more effective than the older live vaccine Zostavax in preventing zoster. Treatment includes IV acyclovir, pain control with agents such as gabapentin or pregabalin, and supportive care.

Asset Subtitle

Jess Hatfield

Meta Tag

Author List Adam Wood, Dania Bairuty, Jess Hatfield, Justin Jacobs

Category Clinical Vignettes

Concept Varicella-Zoster Virus

Concept Herpes Zoster Ophthalmicus

Concept Meningoencephalitis

Concept Lumbar Puncture

Concept Cerebrospinal Fluid

Distinguished Non-Finalist

Presenter Organization Texas A&M School of Medicine

Presenting Author Jess Hatfield

Track Adult

Keywords

varicella zoster virus

herpes zoster ophthalmicus

VZV meningoencephalitis

intravenous acyclovir

post-herpetic neuralgia

lumbar puncture

CSF PCR

uncontrolled diabetes

Shingrix vaccine

Zostavax

Varicella-Zoster Virus

Herpes Zoster Ophthalmicus

Meningoencephalitis

Lumbar Puncture

Cerebrospinal Fluid