Zoster Sine Herpete Masquerading as Central Nervous System Vasculitis

Area of Science:

• Neurology
• Infectious Diseases
• Vascular Neurology

Background:

• Varicella zoster virus (VZV) central nervous system (CNS) vasculopathy is rare.
• Zoster sine herpete, VZV vasculopathy without a rash, is even rarer.
• HIV patients non-compliant with antiretroviral therapy are at risk for opportunistic infections and neurological complications.

Observation:

• A 34-year-old male with HIV presented with headache and numbness, initially diagnosed with Mycobacterium avium complex (MAC) and immune reconstitution inflammatory syndrome (IRIS).
• He later developed stroke-like symptoms including lethargy, aphasia, and dysphagia.
• Cerebral angiography revealed multifocal stenosis consistent with vasculitis.

Findings:

• Cerebrospinal fluid (CSF) PCR confirmed VZV, diagnosing CNS vasculopathy due to zoster sine herpete.
• The patient was treated with high-dose steroids and intravenous acyclovir.
• Symptoms improved, and he was discharged for follow-up.

Implications:

• This case underscores the importance of considering VZV infection in CNS vasculitis, especially when a rash is absent.
• Early diagnosis of zoster sine herpete can prevent severe neurological sequelae like stroke.
• High index of suspicion is crucial for VZV masquerading as other CNS conditions in immunocompromised patients.