Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2024 Sep 8;16(9):e68926.
doi: 10.7759/cureus.68926. eCollection 2024 Sep.

Atypical Presentation of Varicella-Zoster Virus Encephalitis: A Case Report

Norah T Al-Muwallad  1 , Ahmed Al-Dhahi  1 , Hanan K Aljaidi  2 , Maram Al-Balawi  1
Affiliations
Case Reports

Atypical Presentation of Varicella-Zoster Virus Encephalitis: A Case Report

Norah T Al-Muwallad et al. Cureus. .

Abstract

The varicella-zoster virus (VZV) is a neurotrophic alpha herpesvirus that only affects humans. Once infected (often in childhood), VZV causes varicella (chickenpox) before becoming dormant in the cranial nerve (CN) and dorsal root ganglia. It can reactivate after a period of time, resulting in zoster (shingles), which is occasionally followed by post-herpetic neuralgia. This case highlights a patient who presented with vague ear pain and multiple CN palsy, including CN VIII, IX, and X, preceded by a common cold symptom one week ago. Shortly after, he developed severe pain in his left ear and sought medical care at an ENT clinic. The diagnosis was lymphadenopathy, and he received pain medication and a single dose of antibiotics. The patient was conscious, alert, and oriented. He had no fever with normal WBC. Clinical examination revealed multiple CN palsies. Neuroimaging showed normal study. To address potential bacterial infection, the patient was given vancomycin and ceftriaxone as well as acyclovir after a lumbar puncture was performed. The CSF analysis revealed elevated lymphocytes and VZV DNA was detected in the CSF by using polymerase chain reaction. This is an atypical presentation of VZV encephalitis as the patient presented mainly with ear pain. The neurological complications, including CN palsies related to active CNS varicella-zoster infection, and meningeal involvement were clinically improved with empirical medications. The CSF analysis confirmed the diagnosis. Early diagnosis and treatment with antiviral medication are key to optimizing clinical outcomes.

Keywords: brain infection; ear pain; encephalitis; fatal disease; varicella-zoster virus; vzv.

PubMed Disclaimer

Conflict of interest statement

Human subjects: Consent was obtained or waived by all participants in this study. Tabuk Institutional Review Board (KSA:H-07-TU-077) issued approval Exempt. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. MRI of the brain with contrast, fluid-attenuated inversion recovery (FLAIR) sequence showing normal grey-white interface with no area of abnormal signal intensity, no evidence of mass lesion, no area of abnormal enhancement lesion, and no gross vascular abnormality.
See this image and copyright information in PMC

References

    1. Varicella-zoster virus infections of the central nervous system - prognosis, diagnostics and treatment. Grahn A, Studahl M. https://pubmed.ncbi.nlm.nih.gov/26073188/ J Infect. 2015;71:281–293. - PubMed
    1. Reactivation of varicella presenting as pseudotumor cerebri: three cases and a review of the literature. Ravid S, Shachor-Meyouhas Y, Shahar E, Kra-Oz Z, Kassis I. Pediatr Neurol. 2012;46:124–126. - PubMed
    1. Neurologic complications of the reactivation of varicella-zoster virus. Gilden DH, Kleinschmidt-DeMasters BK, LaGuardia JJ, Mahalingam R, Cohrs RJ. N Engl J Med. 2000;342:635–645. - PubMed
    1. Varicella-zoster virus: atypical presentations and unusual complications. Gnann JW Jr. J Infect Dis. 2002;186:0–8. - PubMed
    1. Atypical presentation of varicella-zoster virus encephalitis in an immunocompetent adult. Mpaka M, Karantanas AH, Zakynthinos E. Heart Lung. 2008;37:61–66. - PubMed

Publication types

LinkOut - more resources