11 Apr 2021

3/18/21: VZV Meningoencephalitis

PGY3 Grace Park presented a case of 62 y/o M with history of DM and remote Bell’s Palsy who presents with 1 week of nausea/vomiting, diarrhea with fevers and chills.  He states that he has had 3 episodes of NBNB emesis, 3-4 episodes of watery/non-bloody diarrhea.  Has also had associated lower abdominal pain that is non-radiating, which resolved in the ED.  Fevers were subjective with feeling cold often as well.  Patient has not eaten or drank very much in the past 5 days.

ROS: per HPI

PMH: DM, Bell’s Palsy

Home medications: Glargine 10U qhs, other medications for cholesterol and HTN

Social History: Lives with daughter.  Not currently sexually active.  Past smoker (not to excess), past ETOH (not to excess; last drink many years ago), denies recreational drug use.

Vitals: T 36.7, HR 89, RR 17, BP 176/93, O2 sat 99% on RA

Physical Exam significant for normal exam.

Immediate Events:

  • Witnessed generalized tonic-clonic movements in upper extremities along with decrease in O2 saturation.  Patient responded after 2-3 minutes s/p Ativan and Keppra though did not return to mental baseline.

CBC: WBC 3.4> Hb 10.8/Hct 30.5 <Plt 211 (MCV 86.5, RDW 13.5%)

CMP:

Na 140/K 4.4/Cl 105/HCO3 20/BUN 49/Cr 5.56<Glucose 122

ALP 107>T.protein 5.4/Albumin 2.8/AST 44/ALT 26/Tbili 0.2/Dbili <0.2

Ca 8.2, Mg 2.0, Phos 3.9

Coags: PT 13.1, INR 1.01

ABG: 7.45/24/191/16, 50% FiO2

BCx, UA, UCx, CXR, COVID, RPR all negative.

HIV screen positive but negative antibody or RNA.

CTH done with no acute intracranial abnormality, hemorrhage or mass effect.

MRI Brain: mild global parenchymal volume loss with scattered foci of white matter hyperintensities, slightly progressed from prior.

LP was done which showed:

  • RBC 17
  • PMN 1
  • Glucose 44 (L)
  • Protein 49 (H)
  • CSF culture with no growth x 5days
  • Meningoencephalitis panel positive for VZV

Treatment: Patient was intubated for airway protection after the witnessed seizure.  Neuro was consulted and patient was started on Keppra.  EEG showed no seizure activity and Renal consulted given concern for uremia and he was initiated on HD.  Patient LP results remarkable for VZV and was started on IV acyclovir.  Ophtho consulted and saw no ocular involvement of VZV and patient was discharged on PO acyclovir as well as Keppra for provoked, witnessed seizure with plans to re-evaluate for need of Keppra a neuro clinic.

Teaching points:

  1. VZV Meningoencephalitis is the 3rd most frequent viral meningitis with Enterovirus as first and HSV as second.
    • Common features: +/- Herpes zoster exanthema
    • Non-specific neurological symptoms
    • +/- immunocompromise
    • +/- SIRS
    • Presenting symptoms: HA, fever, neck stiffness, and rarely seizure, stroke
  2. Treatment: IV acyclovir and will need ophtho evaluation for VZV retinitis

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