(595) Spreading Like Wildfire: Disseminated Varicella zoster Virus

Introduction: Varicella Zoster Virus (VZV), also known as Human Herpes Virus 3 (HHV-3), is one of the nine herpesviruses known to be highly contagious, affecting populations worldwide. In older individuals, VZV presents as herpes zoster and manifests as a painful dermatomal rash known as shingles. Rarely, herpes zoster can become disseminated and lead to herpes zoster ophthalmicus (HZO), hepatitis, myocarditis, or meningoencephalitis (ME). We present a unique case of VZV ME, VZV myocarditis, and HZO in a immunocompetent host.

Description: We present a 67-year-old female with past medical history of paroxysmal atrial fibrillation on Xarelto, non-insulin dependent type 2 diabetes mellitus, and other comorbidities who presented to the emergency department (ED) due to altered mental status. Patient was unresponsive at home for an unknown duration. CT head without contrast was negative. Patient was acutely hypotensive requiring vasopressor support and in hypoxic respiratory failure. On physical examination, she was unresponsive and had a Glasgow Coma Scale of 3; ultimately intubated for airway protection. Further inspection revealed left periorbital swelling and herpetiform rash following ophthalmic and maxillary divisions of the left trigeminal nerve. Pertinent labs included arterial blood gas showing a pH of 6.95, pCO2 51, pO2 108, bicarbonate 11 (post intubation) and high-sensitivity troponins: 45, 1041; delta 996. In the ED, the patient also had witnessed seizure-like activity, so she was Keppra loaded. Cardiology was consulted to rule out acute coronary syndrome and reported findings consistent with stress-induced cardiomyopathy. Echo revealed an ejection fraction of 30% with grade 1 diastolic dysfunction. Mentation remained compromised despite liberation from sedation and mechanical ventilation. Lumbar puncture was performed, and results suggested an acute VZV infection. A course of prednisone and acyclovir were initiated for treatment and symptoms greatly improved.

Discussion: VZV ME has an incidence of 1 out of every 33,000-50,000 confirmed infections. VZV myocarditis is even more rare and for it to occur concomitantly with ME is sparsely documented in medical literature. This unique case highlights the rarity of disseminated VZV infection and how prompt treatment led to recovery in our patient.