Varicella-zoster meningoencephalitis with concurrent herpes zoster involving mandibular division of left-sided trigeminal nerve: A rare presentation

Varicella-zoster virus (VZV) is a neurotrophic alpha herpesvirus. Once infected in childhood, VZV causes chickenpox before becoming dormant in the cranial nerve and dorsal root ganglia. Complications include post-herpetic neuralgia, Ramsay Hunt syndrome, Guillain–Barre syndrome, transverse myelitis and encephalomyelitis.[1] It involves retrograde trafficking of virus from vesicles on the face to the trigeminal ganglion and then through the ophthalmic branch to cerebral arteries.[2] Herpes zoster, also called shingles, results from reactivation of latent VZV that gains access to sensory ganglia during chickenpox. Herpes zoster produces painful, unilateral vesicles which usually occur in a single or two contiguous dermatomes, more commonly the thoracic and lumbar.[3] Involvement of ophthalmic division of the trigeminal nerve is also known to occur commonly. However, involvement of the maxillary and mandibular divisions of trigeminal nerve by VZV with concurrent occurrence of meningoencephalitis is unusual.[4] We present a rare presentation of VZV involving the mandibular division of the trigeminal nerve with concurrent meningoencephalitis that was diagnosed with BioFire® FilmArray® equipment (based on multiplex polymerase chain reaction [PCR] assay) from cerebrospinal fluid (CSF). A 70-year-old female presented to the emergency room with a history of burning sensation over the left half of the jaw and the left ear for 6 days, rash over the left jaw (Figure 1a), altered sensorium for 3 days. She had type 2 diabetes mellitus and essential hypertension for 20 years. She had suffered from chickenpox at 10 years of age. General physical examination revealed multiple pearly vesicles over the left jaw extending from the pre-auricular area to the angle of the mouth. Blood pressure was 176/90 mm Hg measured in the right upper limb in supine position, respirations 18/min, pulse 98/min and temperature 98 °F; oral examination revealed candidiasis. Neurological examination revealed Glasgow Coma Scale score 10/15 (E3V3M4), normal-sized pupils bilaterally and reactive to light, bilateral plantar extensor response and nuchal rigidity. Complete haemogram revealed a haemoglobin of 11.1 g/dL, leucocyte count 9600 cell/mm3, platelet count of 227,000/mm3, serum sodium 131 mmol/L and glycosylated haemoglobin (HbA1C) of 7%. Magnetic resonance imaging of the brain was normal. Lumbar puncture was performed and CSF was sent for analysis that revealed total count 60 cells/mm3, lymphocytes 95%, normal glucose (100 mg/dL) and mildly elevated protein (44 mg/dL). BioFire® FilmArray® (based on multiplex PCR) detected varicella zoster. Intravenous acyclovir was administered (800 mg, 8th hourly) for 9 days; her sensorium improved, and skin lesions started clearing by 24 h of treatment initiation (Figure 1b). She was discharged in a stable condition on day 10 of the hospital course. On follow-up after 2 months, the patient is doing well. She is able to walk in her home and do her daily activities.Figure 1: Clinical photograph showing vesicles over mandibular region on day 1 of admission (a) and healing vesicles on the day 10 (at the time of discharge) (b)Viral infections may cause meningitis or mild syndrome of meningoencephalitis. Clinical findings include fever, headache, altered mental status, seizures, disorientation and behavioural disorientation.[5] In this scenario, the patient presented with symptoms suggestive of meningoencephalitis. Detailed history and a quick, thorough examination suggest probable diagnosis of zoster meningoencephalitis supported by the presence of skin rash in the dermatome supplied by the mandibular division of the trigeminal nerve (Figure 1a). The BioFire® FilmArray® meningitis/encephalitis panel is a multiplex PCR assay which detects the aetiology in patients presenting with signs of meningitis,[6] which identifies pathogens within hours,[7] leading to rapid initiation of directed antimicrobial treatment. In the present scenario, BioFire® FilmArray® detected varicella zoster, guiding early initiation of appropriate treatment. This case highlights a rare presentation of varicella zoster meningoencephalitis and the importance of timely detection of the pathogen using multiplex PCR, along with early initiation of antiviral therapy, improves outcome and reduces morbidity and mortality. Financial support and sponsorship Nil. Conflicts of interest The authors are faculty members/residents of Sri Venkateswara Institute of Medical sciences, Tirupati, of which Journal of Clinical and Scientific Research is the official Publication. The article was subject to the journal’s standard procedures, with peer review handled independently of these faculty and their research groups. Use of artificial intelligence (AI)-assisted technology for manuscript preparation The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the preparation of the manuscript and no images were manipulated using AI. Data sharing All authors agree to make data and materials supporting the results or analyses presented in their paper available upon reasonable request. It is up to the author to determine whether a request is reasonable. The data that support the findings of this study are available from the corresponding author. Data will only be shared if it is ethically correct to do so, where this does not violate the protection of human subjects, or other valid ethical, privacy, or security concerns.