Herpes zoster meningitis with multidermatomal rash in an immunocompetent patient
herpes zoster meningitis with multiderma”>Case Report
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American Journal of Emergency Medicine
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Herpes zoster meningitis with multidermatomal rash in an Immunocompetent patient?,??
Abstract
A case of herpetic rash in an immunocompetent patient is described, which was present in multiple dermatomes at the same time. First, patient was thought to have immunodeficiency, but further workup turned out to be negative for it. Patient also had pleocytic lymphocytosis in cerebrospinal fluid, which was suggestive of viral meningitis. Later, the patient responded well to the acyclovir therapy and was discharged home without any sequel. This case illustrates the need for emergency physicians to be extra vigilant for involvement of other dermatomes in case a patient presents with herpetic rash in 1 dermatome because patients with multidermato- mal/disseminated herpetic rash need to be started on airborne isolation in addition to contact precautions to prevent the transmis- sion of disease in health care settings.
Herpes zoster is a relatively common disease characterized by radicular pain and grouped vesicular eruption that is classically distributed over a unilateral dermatome of a cranial or spinal sensory nerve. Reactivation of the virus, which was acquired by a previous exposure and was latent in sensory ganglion, is the primary cause of the disease. It is usually precipitated by stress or a derangement in the immunity [1]. Multidermatomal and dissemi- nated herpes zoster frequently occurs in Immunocompromised patients such as patients with advanced cancer particularly lymphoreticular malignancy or HIV. It can also cause meningitis [2]. Here, we describe an interesting case of mononuclear meningitis and rash in more than 1 dermatome secondary to herpes zoster in an immunocompetent person.
A 27-year-old homosexual man came to our emergency depart- ment with complaints of generalized weakness with headache and neck pain for 2 days. It was associated with an itchy vesicular rash on his left upper back and left arm, which started about 24 hours ago (Figs. 1 and 2). He also complained of intermittent fever and chills for the last 2 days. He denied having nausea, vomiting, or visual problems. The patient had never had such a rash before, and he had 1 male sexual partner for the past 1 year and always used barrier method of protection. He did not report any sick contacts.
On examination, he was a well-built young man with a weight of 82 kg in no acute distress. He was tachycardic at 116 per minute and had a temperature of 100.2?F. Central nervous system examination showed no neurologic deficits with negative Kernigs and Brudzenski signs but was positive for neck stiffness. Skin
? Grant: We declare no source of support in the form of equipment, drugs, or grant for the work presented.
?? Disclosure: This case report and patient management were performed at
Medisys Health Network, NY, USA.
examination revealed multiple vesicular erythematous lesions in the areas of the roots supplied by C6, C7, C8 (Dorsal surface of the arm), and C8, T1 (ventral surfaces of left arm and forearm), and back (C7, C8). Laboratory examination was normal including white blood cell count of 9200 mm/dL.
Patient was immediately started on airborne and contact precautions to prevent the transmission of disease to others and was admitted with a diagnosis of multidermatomal herpes zoster with suspected meningitis, and a spinal tap was done, which revealed a cell count of 50 (lymphocytes, 86%, and neutrophils, 10%). He was found to have mononuclear meningitis secondary to zoster with pleocytic lymphocytosis. HIV enzyme-linked immuno- sorbent assay test was done and was found to be negative. Because this patient had high suspicion of HIV, a nucleic acid amplification test was performed, but it turned out to be negative for HIV virus. Later, patient improved clinically with intravenous acyclovir and was discharged on the fourth day of the admission on oral acyclovir to complete 2 weeks of treatment.
Herpes zoster is caused by the varicella zoster virus. After an initial exposure either in the form of immunization or infection, it remains latent in one of the sensory dorsal root ganglia. On reactivation, it replicates along the course of the nerve and manifests as a vesicular skin rash [1]. There are multiple neurologic complications of its reactivation. The classic clinical manifestations are several groups of painful vesicles situated unilaterally within the same dermatome. It is unusual to have a zoster infection in more than 1 dermatome and extremely rare to have involvement of 2 widely separated regions at one time [3]. Another known complication of the varicella zoster virus reactivation is Aseptic meningitis, characterized by mild cerebrospinal fluid mononuclear pleocytosis and a small increase in protein levels. It may present with or without the classical signs and symptoms of meningitis [2].
The incidence of zoster is estimated at 2 to 3 cases per 1000 per year (approximately 750000 cases per year). The incidence is much higher in immunocompromised and elderly persons. In the immunocompe- tent population, it presents as painful vesicular rash [2]. There are very few cases reported of herpes zoster with rash and meningitis. Our patient is unique, as he did not have any significant medical history. He was found to be HIV negative, was not on any immunosuppressive medication, and did not have an immunosuppressive disorder.
In conclusion, although rare, multidermatomal herpes zoster with meningitis can occur in healthy patients. This case illustrates the importance of complete physical examination in emergency setting and also reiterates the need to look for lesions in other dermatomes in case if patient has herpetic rash in 1 dermatome. Center for Disease Control suggests starting these patients with disseminated herpes on airborne precautions in addition to contact precautions to prevent the transmission of disease in health care setting.
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Fig. 1. Vesicular erythematous rash on ventral surface of left arm and forearm.
Fig. 2. Vesicular rash on left upper back and dorsal surface of left forearm.
Hemant Goyal MD
Mercer University School of Medicine
Macon, GA 31201 E-mail address: [email protected]
Nirav Thakkar MD
Medisys Health Network, Flushing Hospital Medical Center
Flushing, NY 11355 E-mail address: [email protected]
Medisys Health Network, Flushing Hospital Medical Center
Flushing, NY 11355 E-mail address: [email protected]
Sneha Srivastava MD
Medisys Health Network, Jamaica Hospital Medical Center
Jamaica, NY 11418 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2013.06.021
References
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- Amlie-Lefond C, Jubelt B. Neurologic manifestations of varicella zoster virus infections. Curr Neurol Neurosci Rep 2009 Nov;9(6):430-4.
- Gilden DH, Kleinschmidt-DeMasters BK, LaGuardia JJ, Mahalingam R, Cohrs RJ. Neurologic complications of the reactivation of Varicella-zoster virus. N Engl J Med 2000;342:635-45.