An Atypical Case of Varicella Meningitis in a Young Immunocompetent Male Patient With a Possible Concomitant Case of Ramsay-Hunt Syndrome

Varicella zoster virus (VZV) is a single-stranded enveloped RNA virus that is a common cause of chickenpox and herpes zoster. Herpes zoster (shingles) presents with a painful rash in a dermatomal distribution. Ramsay-Hunt syndrome (herpes zoster oticus) is a specific form of shingles, which occurs due to viral reactivation in the geniculate ganglion of cranial nerve VII. It can cause the triad of symptoms of ipsilateral facial paralysis, ear pain, and vesicles in the auditory canal or on the auricle. VZV is also a rare cause of aseptic meningitis, which occurs more commonly in immunodeficient rather than immunocompetent individuals. VZV meningitis can occur with or without the stereotypical rash, which may be very minimal if present. Here, we present a case of a 30-year-old immunocompetent man who presented to his local emergency department (ED) after failed treatment of otitis media and two syncopal events. ED evaluation was positive for nuchal rigidity, scalp tenderness, and an enlarged lymph node on his right posterior neck. PCR analysis was positive for VZV meningitis without overt rash. His only skin finding was erythematous patches in the right auditory canal with a bulging tympanic membrane. His auditory symptoms did not improve with adequate antibiotic treatment, meaning his symptoms were likely viral in nature. The treating infectious disease physician felt his auditory symptoms were related to his VZV infection; however, no confirmatory tests were completed. He was discharged on hospital day 4 and completed a total of 14 days of acyclovir 500mg three times a day. Additionally, we discuss the implications of intravenous acyclovir therapy in mild VZV meningitis in young immunocompetent individuals and the role oral valacyclovir therapy can play.