Case Presentation: 28-year-old male with history of migraines first presented to a local urgent care with frontal headache. He was discharged home after his headache improved with ketorolac. His headache recurred a day later with new onset of fever, photophobia, nausea and vomiting, so he went to emergency department. He denied weakness, numbness, rash, insect bite, recent sick contacts or travel, alcohol or illicit drug use. Vitals showed mild fever at 100.4ºF. Physical exam was without any meningeal signs. Complete blood count and comprehensive metabolic panel were within normal range. MRI brain with and without contrast showed no acute abnormalities. Lumbar puncture showed clear colorless cerebral spinal fluid (CSF) with CSF protein 91mg/dL, CSF glucose 45mg/dL, CSF WBC 445 cells/mm3 with 95% lymphocytes and CSF RBC 5 cells/mm3. CSF and serum infectious workup were sent. As CSF analysis was equivocal for bacterial versus aseptic meningitis, he was started on empiric IV vancomycin and ceftriaxone while waiting for workup results. CSF was positive for varicella zoster virus (VZV) PCR with viral copy at 5085 copies/mL and negative for West Nile virus IgM, E. Coli K1 PCR, H. influenza PCR, Listeria monocytogenes PCR, Neisseria meningitidis PCR, Streptococcus pneumoniae PCR, cytomegalovirus PCR, enterovirus PCR, herpes simplex virus (HSV) 1 PCR, HSV-2 PCR, human herpes virus 6 PCR, Cryptococcus neoformans PCR, Toxoplasma gondii PCR and VDRL. Serum infectious workup showed negative blood cultures, West Nile virus IgM, Rickettsia rickettsii IgM, B. burgdorferi PCR, HSV PCR, syphilis screen, VZV PCR, mumps IgM, HIV antigen/antibody and EBV PCR. IV acyclovir, IV fluids and oral analgesics were initiated and continued until his headache subsided on Day 5. He remained afebrile and had no rash eruption during his hospitalization. He was discharged home with oral valacyclovir to complete a total of 14-day course.
Discussion: VZV typically reactivates and causes infection in elderly, immunocompromised patients. However, VZV meningitis can be seen in young, immunocompetent patients as well. Most present with headache. Like our patient, fever and rash may not be present at initial presentation. Without the classic VZV rash, it is hard to differentiate VZV meningitis from other viral meningitis based on symptoms alone. In addition, our patient’s history of migraines further complicated his clinical picture as migraines can present similarly without the fever. CSF analysis may also have the typical viral meningitis pattern and cannot distinguish the different viral meningitis from each other. Thus, diagnosis relies on CSF VZV PCR testing. While antivirals have shown to prevent disease progression and promote healing in both acute retinal necrosis and cutaneous herpes zoster, two other VZV manifestations in immunocompetent patients, antiviral treatment of VZV meningitis is not as well studied. Nonetheless IV acyclovir is recommended for VZV meningitis treatment as it reduces viral replication, a key process in the pathogenesis of VZV meningitis. Several case reports and series also reported good clinical course with no significant sequelae for those who were treated with IV acyclovir.
Conclusions: VZV meningitis should be considered in young, immunocompetent patients who present with persistent headache. As the classic herpes zoster rash is not always present, CSF VZV PCR is used to diagnose VZV meningitis. Patients should be treated with IV acyclovir to promote early recovery.