Herpes Zoster Ophthalmicus With Orbital Inflammation and Viral Meningitis in an Immunocompetent Patient

Common ocular manifestations of Herpes zoster ophthalmicus (HZO) include conjunctivitis, keratitis, anterior uveitis and ocular hypertension. Immunosuppressed patients are at an increased risk of sequelae including orbital inflammation and meningitis. We present a case of a 47-year-old immunocompetent patient who presented with acute orbital inflammation and viral meningitis, on a background of recent HZO without ocular involvement. Magnetic resonance imaging (MRI) demonstrated enhancement and enlargement of the left extraocular muscles, lacrimal gland and optic nerve sheath and enhancement of the left trigeminal nerve in the prepontine segment extending into the cavernous sinus. A lumbar puncture revealed elevated mononuclear cells consistent with viral meningitis. Cerebrospinal fluid polymerase chain reaction was negative for viruses. The patient was initially treated with intravenous acyclovir, which was followed by oral acyclovir. Oral prednisolone was commenced to treat the orbital inflammation. On 10-week follow-up, inflammatory signs had improved; however, the patient had persisting diplopia, which was managed with prismatic correction.