Varicella Zoster Virus Meningoencephalitis With an Atypical Presentation of Chest Pain, Impaired Memory, and Seizure

Neurologic complications of varicella zoster virus (VZV) reactivation can be associated with considerable mortality and morbidity. Aseptic meningitis associated with VZV infection is rare, occurring in 0.5% of immunocompetent individuals. One third of VZV-related neurologic disease occurs without the classic herpes zoster exanthema, making early recognition more difficult.

A 60-year-old man presented to the emergency department with chest pain and impaired memory that he attributed to a transient ischemic attack as suggested by an urgent care facility 1 day earlier. He suffered a seizure while in the emergency department and was admitted to the intensive care unit. A computed tomography scan of his head and a magnetic resonance imaging scan were both negative for acute findings. An abnormal electroencephalogram consistent with an encephalopathy together with his new-onset seizure triggered a lumbar puncture that was positive for VZV. He was placed on acyclovir and was discharged from the hospital 5 days after admission. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The typical presentation of a VZV central nervous system infection occurs with a sudden onset of fever, headache, nuchal rigidity, and focal neurologic signs. Our patient's recent impaired memory and subsequent seizure were likely manifestations of the developing VZV meningoencephalitis, while his chest pain may have correlated with subsequent development of a vesicular rash. Seizures are encountered in 11% of patients with VZV central nervous system infection, and VZV has recently been associated with cerebral vasculopathy. Awareness of alternative presentations for herpes zoster and meningitis is important in cases without classic symptoms to enable diagnosis and prevent delays in treatment.