Varicella-Zoster Virus Reactivation Presenting as Cranial Neuritis Without Rash in Late Pregnancy: A Case Report

Neurological complications of reactivated varicella-zoster virus (VZV) are uncommon in immunocompetent individuals and are rarely reported during pregnancy. VZV reactivation may cause cranial neuritis, including Ramsay Hunt syndrome, or may present without cutaneous lesions as zoster sine herpete, complicating diagnosis.

We report the case of a 26-year-old primigravida at 37 weeks of gestation who presented with paresthesia of the left side of the tongue, dizziness, and subsequent left-sided facial nerve palsy. Brain magnetic resonance imaging showed no abnormalities. Audiometry demonstrated mild high-frequency hearing loss on the left side. Cerebrospinal fluid analysis revealed lymphocytic pleocytosis, and polymerase chain reaction detected VZV DNA. The patient received intravenous acyclovir (10 mg/kg every 8 h for 10 days). No vesicular rash developed during the clinical course. The clinical presentation was consistent with VZV-associated cranial neuritis involving Cranial Nerves VII and VIII within the spectrum of zoster sine herpete. Intravenous acyclovir therapy was administered for 10 days, and corticosteroids were discontinued after virological confirmation. Delivery was performed by planned cesarean section due to breech presentation, and the newborn was healthy with no signs of neonatal varicella infection. At hospital discharge, the mother had persistent House-Brackmann grade V facial paralysis. One month after symptom onset, the facial paresis had completely resolved.

VZV reactivation in pregnancy may present as isolated cranial neuritis without rash. Cerebrospinal fluid PCR is essential for diagnosis in atypical cases. Early antiviral treatment is associated with favorable maternal and fetal outcomes. Only a few cases of VZV meningitis or encephalitis in pregnant patients have been reported in the literature. Although immunodeficiencies are usually associated with these clinical manifestations, pregnancy is a condition in which various changes occur in the woman's immune system. This case highlights that VZV reactivation may present as cranial neuropathy without rash during pregnancy. Detection of VZV DNA in cerebrospinal fluid is essential for diagnosis in atypical presentations. Early recognition and antiviral therapy are important for maternal neurological outcomes and are safe for the fetus.