Herpes zoster and aseptic meningitis in a previously healthy child

Abstract

We describe an 8-year-old boy with aseptic meningitis in association with herpes zoster, a rare complication in immunocompetent children. This previously healthy boy, who had a history of chickenpox at the age of 6 months, presented with grouped, painful vesicular lesions of the right thoracic dermatomes 7–9. A clinical diagnosis of herpes zoster was made and symptomatic local treatment was initiated. Five days later the child had an acute onset of intense headache. On physical examination, the boy was in a moderately well condition and subfebrile with an axillary body temperature of 37.8C; all other vital signs were normal. Herpes zoster of the right thoracic wall was still present, however, no vesicles could be found on the face, ear or mouth. Neurological examination revealed a stiffness of the neck with positive Kernig sign and constant bilateral fasciculation of the periorbicular muscles, albeit more pronounced on the right side. Peripheral facial muscle weakness was not present. Lumbar puncture revealed 47 leukocytes/ll with 87% lymphocytes and 13% polynuclear granulocytes. CSF glucose and protein levels were within the respective normal ranges. A differential diagnosis of aseptic meningitis caused by reactivated varicella zoster virus (VZV) or herpes encephalitis was made and treatment with acyclovir i.v. (1500 mg/m 2 /d in three divided doses) was started empirically. Periorbicular fasciculations stopped 6 h after the first dose of acyclovir. Bacterial culture of CSF yielded no growth. VZV DNA was recovered from CSF by polymerase chain reaction (PCR) whereas herpes simplex virus DNA was not detected. VZV antibodies in CSF were not analysed. However, the presence of VZV DNA in CSF was strong presumptive evidence of VZV infection of the central nervous system, and acyclovir treatment was continued for 7 days. The boy’s general condition normalised gradually over the next few days. During 12 months of follow-up, no neurological or cutaneous complications have occurred. Children who contract varicella in the 1st year of life are at increased risk for zoster during childhood, but it is