Abstract
A 68- year – old male was admitted to ER of Referral Imam Khomeini hospital with abrupt commence of fever accompanied with debilitating non-radiating headache, photophobia, ataxia and cluster of confluent vesicles on right side of forehead with swelling of right eyelid. All his symptoms started after receiving Botulinum injection on the same week before admission and he had never had similar manifestations beforehand.
 His medical history was remarkable for hyperlipidemia, hypertension and right side Blepharospasm for which he received Botulinum injection every 6 months. He was on medication for the rest of his medical problems. He was not on any immunosuppressive medication and did not suffer from any disease weakening the immune system. His family history was unremarkable for any similar problems.
 In medical exam, he was ill but not toxic, his vital signs were blood pressure of 135/80 mmHg, heart rate of 76, respiratory rate of 17 and oral temperature of 38.5Ĉ. He had vesicles on his right forehead. Heart sounds were regular without murmur. Lungs were clear. Abdominal examinations were inconspicuous.
 In neurological examinations, he was confused and disoriented to time and place. Cranial nerves were without any pathological findings except for positive Marcus Gunn of affected side and blurring of right optic disk margin. No muscle atrophy was seen. Muscle force showed no weakness. He was ataxic. Sensory examination was normal. Reflexes were checked and were within normal limits and symmetric.
 Computer tomography (CT) scan of head was unremarkable and his MRI scan did not reveal any information compatible with his symptoms.
 Due to the sudden onset of fever with headache and confusion, encephalitis was suspected and empirical therapy with antibiotics was started and LP was performed which indicated pleocytosis in CSF. According to the vesicles on the skin and with suspicion of Varicella encephalitis, PCR was sent for diagnosis of VZV. Subsequently, his condition got dramatically better and symptoms diminished after acyclovir was started.
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