Varicella-Zoster Virus Meningoencephalitis in a Lung Transplant Recipient

Abstract

Introduction Solid organ transplant (SOT) recipients are susceptible to an array of infections and atypical clinical presentations. Varicella-zoster virus (VZV) becomes latent in dorsal root ganglia after the initial infection, and reinfection commonly presents with a painful rash. In SOT recipients, VZV can present as meningoencephalitis without an associated rash and is associated with high morbidity and mortality. We present a rare case of VZV meningoencephalitis in a lung transplant recipient. Case Report A 71-year-old woman with a history of bilateral lung transplant in 2014 and rheumatoid arthritis presented to an outside hospital with one week of fever and confusion. She was subsequently intubated after suffering a generalized tonic-clonic seizure. Upon transfer to our facility she had an unremarkable exam including skin exam. She was started on vancomycin, ceftriaxone, ampicillin, acyclovir, and fluconazole for presumed meningoencephalitis. Lumbar puncture revealed 100 WBC/mm3, with 93% lymphocytes. The cerebrospinal fluid (CSF) glucose was 125 mg/dL, protein was 233 mg/dL, cultures were negative but qualitative polymerase chain reaction (PCR) was positive for VZV. Electroencephalogram (EEG) revealed status epilepticus and magnetic resonance imaging (MRI) showed a T1 and T2 hypointensity in the right posterior periventricular white matter and scattered foci in bilateral cerebral white matter. Her status epilepticus was treated with antiepileptics and resolved by hospital day eight. She received 14 days of intravenous (IV) acyclovir 10mg/kg every 8 hours and was transitioned to oral valacyclovir for suppression for two months. On discharge her mental status had significantly improved but had not fully returned to her baseline. Summary Zoster is a common, benign disease caused by VZV and associated with painful cutaneous lesions. However, neurological manifestations without a rash are possible in SOT patients. Lumbar puncture and CSF analysis are crucial for diagnosis and typically shows lymphocytosis with viral culture, antibody, or PCR positive for VZV. Treatment of choice for VZV encephalitis is IV acyclovir for 7 days in the immunocompetent patient and 14 days in the immunosuppressed patient. This case demonstrates how prompt recognition and treatment of VZV meningoencephalitis can decrease mortality and neurologic disease in the immunocompromised patient. Solid organ transplant (SOT) recipients are susceptible to an array of infections and atypical clinical presentations. Varicella-zoster virus (VZV) becomes latent in dorsal root ganglia after the initial infection, and reinfection commonly presents with a painful rash. In SOT recipients, VZV can present as meningoencephalitis without an associated rash and is associated with high morbidity and mortality. We present a rare case of VZV meningoencephalitis in a lung transplant recipient. A 71-year-old woman with a history of bilateral lung transplant in 2014 and rheumatoid arthritis presented to an outside hospital with one week of fever and confusion. She was subsequently intubated after suffering a generalized tonic-clonic seizure. Upon transfer to our facility she had an unremarkable exam including skin exam. She was started on vancomycin, ceftriaxone, ampicillin, acyclovir, and fluconazole for presumed meningoencephalitis. Lumbar puncture revealed 100 WBC/mm3, with 93% lymphocytes. The cerebrospinal fluid (CSF) glucose was 125 mg/dL, protein was 233 mg/dL, cultures were negative but qualitative polymerase chain reaction (PCR) was positive for VZV. Electroencephalogram (EEG) revealed status epilepticus and magnetic resonance imaging (MRI) showed a T1 and T2 hypointensity in the right posterior periventricular white matter and scattered foci in bilateral cerebral white matter. Her status epilepticus was treated with antiepileptics and resolved by hospital day eight. She received 14 days of intravenous (IV) acyclovir 10mg/kg every 8 hours and was transitioned to oral valacyclovir for suppression for two months. On discharge her mental status had significantly improved but had not fully returned to her baseline. Zoster is a common, benign disease caused by VZV and associated with painful cutaneous lesions. However, neurological manifestations without a rash are possible in SOT patients. Lumbar puncture and CSF analysis are crucial for diagnosis and typically shows lymphocytosis with viral culture, antibody, or PCR positive for VZV. Treatment of choice for VZV encephalitis is IV acyclovir for 7 days in the immunocompetent patient and 14 days in the immunosuppressed patient. This case demonstrates how prompt recognition and treatment of VZV meningoencephalitis can decrease mortality and neurologic disease in the immunocompromised patient.