Two Cases of Varicella Zoster Virus Meningitis without Fever and Rash: An Unexpected Clinical Presentation

Abstract

Aseptic meningitis caused by Varicella-Zoster virus (VZV) is a rare phenomenon in the healthy population. Immunocompromised patients are predominantly affected by viral reactivation, characterized by rash and neurological symptoms, and meningitis as a rare complication. Herein, we report two cases of VZV meningitis in adult patients without rash and fever over a 4-month period. The first case was an immunocompetent 37-year-old male who presented with persistent headache, agitation and unclear speech. The second case was an immunocompromised 76-year-old male who was admitted to the emergency department with confusion, disorientation, dizziness, loss of consciousness, pain in the lower left extremities and difficulty in walking. Cerebrospinal fluid (CSF) analysis in both patients revealed a high leukocyte cell count with 97% lymphocytes. CSF gram staining and culture were negative. CSF polymerase chain reaction (PCR) analysis indicated VZV infection. Both patients were administered acyclovir for 14 days and were discharged without any neurological sequela. This case report series highlight the presentation of VZV as aseptic meningitis in both immunocompetent and immunocompromised patients without the typical clinical symptoms and should always be considered by the clinicians.