Local Varicella Zoster Infection As A Rare Reason For Encephalitis

Abstract

Scientific BACKGROUND: Encephalitis is a clinical picture including an acute pyretic disease together with findings of meningeal involvement and cerebral effect, and cellular reaction and high protein level in brain cerebrospinal fluid (CSF). There are many infection agents involving the nervous system. Among these agents, varicella zoster virus (VZV) has been infrequently reported. Neurological complications of VZV may be listed as encephalitis, cerebral ataxia, meningitis, cerebral infarct and facial paralysis. Rare complications of cervicocranial herpes infections are encephalitis, cerebral angitis and myelitis. This paper presents a case who have developed encephalitis following VZV infection related ophthalmic geniculate herpes and discusses the case accompanied by similar cases in the literature.

CASE: History of the eighty-three year-old woman, who referred to our clinic with complaints of failure in consciousness developed after swelling on left eyelid and vesicular desquamations, indicated pricking and watering in the left eye, then sleepiness and difficulty in communication nearly four days before confusion in consciousness. Results of neurological examination indicated that there was confusion in consciousness, she could open her eyes upon painful stimulus and she uttered meaningless words. There were edemas around the left eye, vesicular, crusty lesions on the left which seemed to be olfactory traces, hyperemia in the left eye, left pupil dilatation, limitations in inner deviation and outer look. There was reaction to light at both sides. There was no implication for motor lateralization. Babinski bilateral was irrelevant. There was no pathology other than leukocytosis in routine biochemical examinations. Lumber ponction indicated no pathology other than moderate level of protein in CSF biochemical examination and moderate increase in the number of cells in direct examination. Herpes simplex virus (HSV) PCR was negative and there was no reproduction in VZV cell cultures. CSF bacteriological, microbacteriological and cytological examination results were within normal ranges. EEG indicated common slowness in background rhythm activity. Pre- and post-contrast cranial CT and MRI of the case indicated no pathology other than senile atrophy and chronic ischemic changes. There was preseptal orbital cellulitis in pre- post-contrast orbita MRI and paranasal sinus CT imaging. The case was treated with Acyclovir and Cephtriaxon intravenously for 25 days. The conscious improved and eye related findings reduced in the second week of therapy. Repeated CSF examination indicated no change in the high level of protein (72 mg/dl), but no cell reproduction was observed. Control EEG indicated partial improvement in slowness of background rhythm activity. No pathology was determined in control pre- post-contrast cranial MRI.

CONCLUSION: Accompanied by cases in the literature, this paper presents an encephalitis case developed after ophthalmic geniculate herpes related to VZV infection which is rare but a known reason for encephalitis. We want to share this case with you due to such characteristics as third and sixth cranial nerve involvement despite no early isolation and normal cranial imaging methods, significant reduction in confusion and pathologies determined in EEG and CSF examinations in terms of laboratory and clinical findings as a result of the applied therapy, existence of no immunosuppressive factor other than old age.