Varicella Zoster meningitis presenting in an Immunocompetent adolescent

Varicella zoster virus (VZV) establishes dormancy following primary infection and reactivates typically in the elderly and immunocompromised hosts. Neurological complications can occur but are rare in immunocompetent hosts. They are also rarely seen without the typical rash and high fever. We describe a case of varicella zoster meningitis in a healthy 13-year-old girl who presented with headache but without fever or a rash. 8 day history of severe headache, poor appetite, lethargy and photosensitivity. This headache was poorly responsive to NSAIDs and triptan. Fundal examination revealed swollen discs, which prompted the need for a lumbar puncture, following a normal CT Brain.

Varicella zoster virus confirmed on CSF viral panel and FilmArray. CSF revealed a pleocytosis. Blood results unremarkable. Fundal examination revealed swollen discs. CT Brain normal. MRI Brain normal. Confirmed: Varicella Zoster Meningitis.

Acyclovir (10mg/kg every 8 hours) for 21 days. Analgesia. IV fluids.

This case report describes an unusual presentation of varicella zoster virus (VZV) positive aseptic meningitis in an immunocompetent adolescent who presented with a headache but no rash or fever. This highlights the need to recognise that VZV may be a potential cause of aseptic meningitis in a healthy child despite atypical presentations.