SHM Converge Scientific Abstract ePoster Gallery-Immunocompetent Patient With VZV Meningoencephalitis

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This case describes a 62-year-old immunocompetent man who presented after a new-onset generalized tonic-clonic seizure. On arrival, he was agitated and briefly desaturated, but had no focal neurologic deficits. Exam revealed a vesicular, dermatomal rash extending from the left chest wall to the left axilla, raising concern for herpes zoster with possible central nervous system involvement.<br /><br />Initial workup showed lactic acidosis and a negative head CT. Because of intermittent confusion and suspicion for varicella zoster virus (VZV) meningoencephalitis, he underwent lumbar puncture and was started empirically on IV acyclovir. CSF studies demonstrated lymphocytic pleocytosis, mildly elevated protein, normal glucose, and negative cultures. CSF PCR was positive for VZV, confirming the diagnosis. HIV testing was negative. MRI brain showed bilateral mesial temporal lobe T2 signal abnormalities without hemorrhage or enhancement, supporting encephalitic involvement. He was treated with IV acyclovir and later transitioned to oral valacyclovir after the skin lesions crusted, completing 14 days of therapy.<br /><br />The discussion emphasizes that VZV can reactivate from latent infection to cause shingles and, more rarely, meningitis or encephalitis. Although VZV is a recognized cause of aseptic meningitis and viral encephalitis, meningoencephalitis in immunocompetent patients is uncommon and may be underdiagnosed, especially when classic symptoms such as fever, headache, or neck stiffness are absent. In this patient, the rash was a key clue that enabled prompt treatment.<br /><br />The main takeaway is that clinicians should maintain a low threshold to test for VZV in patients with unexplained seizure, confusion, or meningitis/encephalitis symptoms, even in immunocompetent hosts, because early recognition and antiviral therapy may prevent serious neurologic complications and death.

Asset Subtitle

Kristin Nascimento

Meta Tag

Author List Kristin Nascimento, Maxwell Hershey, Pinky Jha, Shanna Su

Category Clinical Vignettes

Concept Varicella-Zoster Virus

Concept Meningoencephalitis

Concept CSF VZV PCR

Concept Intravenous Acyclovir

Concept Herpes Zoster

Distinguished Non-Finalist

Presenter Organization Medical College of Wisconsin

Presenting Author Kristin Nascimento

Track Adult

Keywords

varicella zoster virus

VZV meningoencephalitis

generalized tonic-clonic seizure

herpes zoster

immunocompetent patient

cerebrospinal fluid PCR

lymphocytic pleocytosis

acyclovir treatment

encephalitis

temporal lobe MRI

Varicella-Zoster Virus

Meningoencephalitis

CSF VZV PCR

Intravenous Acyclovir

Herpes Zoster