(613) Varicella zoster Meningitis and Acute Respiratory Distress Syndrome in an Immunocompetent Patient

Introduction: Varicella zoster virus (VZV) belongs to the herpesvirus family that presents as chickenpox, usually in children, following which the virus resides latent in the dorsal root ganglion. Reactivation of the virus due to immune suppression or illness manifests as herpes zoster later in life.
A herpetic rash in a dermatomal distribution, typically on the trunk and back is the usual presentation. Aseptic meningitis caused by VZV is usually seen in the immunosuppressed but rarely in the immunocompetent. Acute respiratory distress syndrome (ARDS) and pneumonia associated with VZV is another rare manifestation.
We present the case of an immunocompetent patient with dermatomal VZV infection complicated by meningitis and ARDS.

Description: A 61 y-o woman presented with worsening dyspnea and altered mentation of 1 week duration. Her past history was significant for type 2 diabetes mellitus, CKD3, hypertension and obstructive sleep apnea. Diagnostic workup showed hypercapnic and hypoxemic respiratory failure requiring non-invasive ventilation. A vesicular rash with erythematous base was noted on the back in the T4 dermatomal distribution. Chest imaging showed bilateral extensive air-space disease and infiltrates. She was intubated for worsening hypoxemia. As neuroimaging ruled out stroke, CSF analysis was performed via lumbar puncture. CSF WBC 230/cu.mm (monocytes 47%, lymphocytes 32%, PMN 16%), RBC 9/cu.mm, protein 81 mg/dl, glucose 100 mg/dl. PCR was positive for VZV and negative for HSV.
She was treated with intravenous acyclovir for 4 weeks and made full neurological recovery within a week, but prolonged mechanical ventilation for ARDS requiring tracheostomy for persistent respiratory failure.

Discussion: Only 0.5% of patients affected with VZV develop meningitis, presumably due to virus spread via afferent nerves to the central nervous system (CNS) and the meninges. Hematogenous spread to the CNS is another possible mechanism. Concomitant meningitis and ARDS is extremely uncommon especially in the immunocompetent host. VZV may not be isolated in bronchial washings and the diagnosis relies on clinical manifestations, serology and the presence of VZV in other sites as our patient.
Our report illustrates a very rare combination of meningitis and ARDS due to VZV in an immunocompetent patient.