Varicella Zoster Virus Aseptic Meningitis: A Misleading Clinical And Laboratory Presentation: Three Case Reports

Abstract

Background: A septic meningitis caused by varicella zoster virus (VZV) reactivation was less described in the literature, Varicella-zoster virus is a neurotropic virus that remain dormant in dorsal root ganglion after primary infection, usually manifested as chickenpox which gets reactivated in immunocompromized state presented usually with vesicular rash complicated with multi-organ affection such as central nervous system. Rarely this characteristic skin rash can be absent initially requiring high clinical suspicion for diagnosis. When no skin lesions are present, a high clinical suspicion is required to reach the diagnosis. In this report we described three clinical of varicella-zoster virus reactivation presented in atypical way in terms of clinical presentation and cerebrospinal fluid analysis. Case presentation: Three patients otherwise healthy were admitted to the hospital with a chief complaint of headache, nausea, vomiting and symptoms suggestive of increased intracranial pressure (IIH). Resembling IIH but due to acute presentation and positive meningeal signs this was unlikely. The clinical examination did not show any neurological deficits or rash except lately in the first case. Lumbar puncture unexpectedly showed high opening pressure with markedly elevated CSF total and high total cell count with lymphocytic predominance which was misleading raising suspicion of tuberculous meningitis. Further CSF analysis, including polymerase chain reaction (PCR) and detection of intrathecal synthesis of antibodies, showed a VZV infection. Clinical follow-up examinations later on proved successful antiviral treatment. Conclusion: In conclusion, absence of typical vesicular rash of varicella zoster initially as well as high opening CSF pressure with high CSF protein even young and previously healthy patients should not rule out consideration of varicella zoster meningitis.