Central nervous system (CNS) Varicella Zoster encephalitis and vasculopathy in an immunocompetent patient Case Report

Abstract Background Varicella zoster virus (VZV) infection, which affects the central nervous system (CNS) in adult patients, may occur with or without concurrent shingles. CNS manifestations include encephalitis and vasculopathy, the latter often manifesting as stroke due to ischaemic lesions involving small arteries. Immunocompromised individuals and those of advanced age are more prone to develop severe disease and also CNS involvement following VZV infection. We present a case of VZV encephalitis and vasculopathy, its symptoms and physical findings that should raise clinical suspicion of the disease, and its treatment and prognosis.Case presentation A 61-year-old man who presented to the emergency department with shingles and altered mental status was diagnosed with encephalitis and ischaemic stroke. Intravenous acyclovir was administered. VZV DNA and serology was detected in his CSF. Enhanced computed tomography (CT) of the brain showed multifocal non-enhancing hypodensities in cortical and subcortical areas. A diagnosis of VZV CNS encephalitis and vasculopathy was made and intravenous acyclovir was continued for 21 days and a short course of prednisolone was prescribed. Magnetic resonance imaging of the brain on subsequent follow-up showed cortical haemorrhage in the remaining areas, but this was less compared to the initial imaging.Conclusion Neuroimaging can detect ischaemic stroke and detection and VZV CSF PCR is a reliable diagnostic tool, as shown in this case. Antiviral treatment and short-term steroid administration can improve outcome. This clinical case highlights the importance of recognition and challenge in the diagnosis of VZV CNS vasculopathy in immunocompetent patients.