A CASE OF HERPES ZOSTER ENCEPAHLITIS
LEARNING OBJECTIVES: Viral pathogens can cause a variety of syndromes when affecting the central nervous system including aseptic meningitis and encephalitis.Varicella zoster virus (VZV) is a rare cause of central nervous system syndromes. We discuss a patient who initially presented with dermatomal zoster whose clinical course was complicated by the development of VZV encephalitis with complications both from the primary disease process and the appropriate therapy.
CASE: 66 yr old Caucasian female with history of rheumatoid arthritis treated with methotrexate who presented with mental status changes. Seven days prior to admission she developed an erythematous rash on back and chest confined to right side of thorax. She was treated with valacyclovir for two days and complained of pain at the site for which she was prescribed vicodin and amitryptyline. The next day she was noted to be disoriented by family and brought to ER. Physical exam revealed an erythematous vesicular rash on her chest and back confined to the T2–T3 dermatome on right side. Neurological exam was within normal limits except that she had difficulty finding words. CT scan of the head on admission was normal and her labs were significant for hyponatremia (123 mmol/l). Urine osmolality was 708 mosm/kg and serum osmolality was 267 mosm/kg consistent with SIADH. She was placed on intravenous (IV) acyclovir and fluid restriction for SIADH. Cerebrospinal fluid (CSF) analysis revealed an elevated white blood cell count (321/cmm) with lymphocytic predominanace (90%) and elevated protein level (115 mg/dL). CSFanalysis for VZV by PCR was positive. On day 3 her creatinine level increased and urinalysis revealed numerous crystals consistent with acyclovir induced nephropathy. The acyclovir dose was adjusted based on renal function and she was given IV fluids. On day 4 she complained of hallucinations and double vision. MRI of the head was normal. She continued to improve with IV acyclovir and hyponatremia resolved. A repeat CSF analysis was negative for VZV by PCR. Patient completed a two week course of IV acyclovir and was discharged on oral valacyclovir for an additional week and neurontin for pain.
DISCUSSION: Herpes zoster encephalitis is rare and very few cases have been reported.We postulate that in this case her immunosuppresed state on methotrexate was the main predisposing factor. This case also highlights the complications of disease process, specifically hyponatremia (SIADH) and adverse effect of treatment (acyclovir induced nephropathy) and how to manage them astutely.
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