Herpes zoster ophthalmicus with atypical occipital lobe and splenial lesions: A case report

A 32-year-old male with past medical history of migraine headaches (last episode 15 years prior) presented with persistent headache lasting 2 days and with associated nausea, photophobia and phonophobia concerning for migraine. Subsequent visits to outside facilities suggested a cortical/subcortical infarct of the left medial occipital lobe secondary to migraines. However, after continued symptoms and the subsequent development of a maculopapular rash along the right orbit and eyelid, suspicion grew that this was not a simple case of migraine induced infarct. Cerebral spinal fluid analysis showed markedly elevated VZV antibodies further raising suspicion. After a 1-week course of high-dose oral valacyclovir the rash and headache resolved. This case demonstrates an atypical pattern of CNS involvement in herpes zoster ophthalmicus, with simultaneous splenial and medial occipital lesions - an imaging pattern not commonly reported in immunocompetent adults. The findings also highlight the importance of a good clinical history and the superior sensitivity of MRI in detecting subtle varicella-zoster-related encephalitic changes when CT is nondiagnostic.