SHM Converge Scientific Abstract ePoster Gallery-Varicella Zoster Virus Meningitis in a Young Immunocompetent Patient

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A 28-year-old immunocompetent man with a history of migraines presented with recurrent headache, fever, photophobia, nausea, and vomiting. He had been seen the day before at urgent care for a frontal headache that improved with ketorolac, but his symptoms returned and worsened, leading to emergency department evaluation. He denied rash, neurologic deficits, sick contacts, travel, substance use, or other clear triggers.<br /><br />On exam, he had only a mild fever and no meningeal signs or focal neurologic deficits. Brain MRI was normal. Lumbar puncture showed clear CSF with elevated protein, normal-to-low glucose, and marked lymphocytic pleocytosis, suggesting viral meningitis but not identifying a specific cause. Because bacterial meningitis could not be excluded initially, he was started on empiric IV vancomycin and ceftriaxone, along with IV fluids and analgesics.<br /><br />Extensive serum and CSF infectious testing was performed. The key positive result was CSF varicella zoster virus (VZV) PCR, with a viral load of 5085 copies/mL. All other major infectious studies were negative, including tests for HSV, enterovirus, bacterial pathogens, cryptococcus, HIV, syphilis, and others.<br /><br />After lumbar puncture, IV acyclovir was started and continued until his headache resolved on hospital day 5. He remained afebrile and never developed a vesicular rash during hospitalization. He was discharged home on oral valacyclovir to complete a total 14-day antiviral course.<br /><br />This case highlights that VZV meningitis can occur in young, otherwise healthy patients and may present without the classic herpes zoster rash. Because symptoms and CSF findings can resemble other viral meningitides, diagnosis relies on CSF VZV PCR. Early treatment with IV acyclovir is recommended and was associated with good recovery in this patient.

Asset Subtitle

Wan Hsiang Chen

Meta Tag

Author List Christopher R. Force, Wan Hsiang Chen

Category Clinical Vignettes

Concept Varicella Zoster Virus Meningitis

Concept Headache

Concept CSF VZV PCR

Concept Intravenous Acyclovir

Concept Rash

Distinguished Non-Finalist

Presenter Organization Houston Methodist Hospital

Presenting Author Wan Hsiang Chen

Track Adult

Keywords

varicella zoster virus

VZV meningitis

viral meningitis

CSF PCR

lymphocytic pleocytosis

immunocompetent

headache

photophobia

acyclovir

valacyclovir

Varicella Zoster Virus Meningitis

Headache

CSF VZV PCR

Intravenous Acyclovir

Rash