Varicella-Zoster Virus Meningitis With Hypoglycorrhachia Mimicking Tuberculous Meningitis: A Case Report

Varicella-Zoster virus (VZV) meningitis poses diagnostic challenges and often presents with atypical clinical and laboratory findings. We present a case of VZV meningitis with hypoglycorrhachia mimicking tuberculous meningitis (TBM). A 65-year-old Japanese woman with a past history of successfully treated tuberculosis presented with a persistent headache. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis and hypoglycorrhachia (CSF glucose: 43 mg/dL, CSF-to-serum glucose ratio: 0.34) with borderline elevated adenosine deaminase ADA level (9.1 IU/L), raising concern for TBM. Head computed tomography (CT) was unremarkable, and chest CT showed only calcified nodules consistent with prior tuberculous infection. The patient met the criteria for <i>possible</i> TBM based on clinical and CSF findings. Empirical treatment with broad-spectrum antibiotics and dexamethasone was initiated for suspected bacterial meningitis. Her symptoms improved rapidly, and both CSF and blood cultures were negative. A multiplex polymerase chain reaction (PCR) test later identified VZV as the causative pathogen. Antiviral therapy was withheld, as the patient's symptoms had fully resolved by the time of diagnosis. She remained well thereafter, with no complications during follow-up. This case illustrates how VZV meningitis can mimic TBM through marked hypoglycorrhachia and a remote history of tuberculosis.