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

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.