A Case of Multiple Intracranial Hemorrhages Due to Biopsy-Proven Varicella Zoster Virus Vasculopathy Without Rash

Varicella zoster virus (VZV) vasculopathy is a rare complication of VZV infection that can lead to severe neurological manifestations, including multiple intracranial hemorrhages. We report the case of an 80-year-old male patient with a history of Parkinson's disease and hypertension who presented with altered consciousness and motor difficulties. Imaging studies revealed recurrent cortical-subcortical hemorrhages in the right frontal lobe. Laboratory tests showed elevated cerebrospinal fluid (CSF) protein, increased CSF cell count, and a significantly elevated VZV IgG antibody index, while CSF VZV DNA was undetectable. A brain biopsy confirmed the diagnosis, showing vasculitis with VZV DNA positivity via real-time polymerase chain reaction (PCR) and immunohistochemistry. The patient was treated with intravenous acyclovir and corticosteroids, which partially improved clinical outcomes. This case highlights the importance of considering VZV vasculopathy as a differential diagnosis in unexplained intracranial hemorrhages, even in the absence of typical skin lesions. Comprehensive diagnostic evaluation, including CSF antibody testing and brain biopsy, is essential for accurate diagnosis and management.