A Fatal Case of Atypical Disseminated Herpes Zoster in a Patient with Meningoencephalitis and Seizures Associated with Steroid Immunosuppression

Abstract

BACKGROUND Herpes zoster is caused by the reactivation of the varicella zoster virus (VZV) and usually presents with vesicular skin lesions with a dermatomal distribution. Disseminated herpes zoster (DHZ) infection is characterized by non-dermatomal skin eruptions, often with involvement of other organs, and occurs in immunocompromised patients. CASE REPORT A 69-year-old man who was treated with prednisolone for amiodarone-associated interstitial lung disease, presented with seizures and altered consciousness. He had an erythematous rash with raised vesicles involving the skin of the genital region, left thigh, and abdomen. Following a diagnosis of DHZ with herpes zoster meningoencephalitis, he was treated with intravenous acyclovir. However, his level of consciousness did not improve, and he died of respiratory failure due to aspiration pneumonia. CONCLUSIONS A diagnosis of DHZ should be considered in immunosuppressed patients treated with steroids who present with seizures. A detailed search for skin eruptions should be conducted to enable early diagnosis and treatment.

Figure 1.

Computed tomography (CT) imaging of the head. (A) Head computed tomography (CT) performed after a seizure showing a low-density area in the left temporal lobe. (B) Bilateral low-density areas in the forehead region of the frontal lobes on head CT performed following discontinuation of acyclovir (arrow), which were suspected to be due to hematoma or edema.

Figure 2.

Disseminated erythematous rashes involving the skin of the genital areas, buttocks, left thigh, and abdomen. (A) An erythematous rash with raised vesicles involving the genital regions and involving the right third to fourth sacral (S3–S4) dermatomes. (B) An erythematous rash with raised vesicles is shown to involve the skin of the buttocks. (C) An erythematous rash with raised vesicles is shown to involve the skin of the left thigh and abdomen, which did not follow the distribution of a dermatome.

Figure 3.

The clinical course of the patient. CRP – C-reactive protein; CSF – cerebrospinal fluid; VZV – varicella zoster virus; HSV – herpes simplex virus; mono – monocyte; seg – segmented neutrophil; WBC – white blood cell.