A Case of Herpes Zoster and Meningitis in a Twice-Vaccinated Healthy Adolescent
Journal of Pediatric Infectious Diseases
A previously healthy 14-year-old girl was transferred to our emergency department on day 4 of her illness with worsening headache and rash. Her symptoms had started with a frontal headache noted to be worse in the mornings. On day 3 of illness, she noticed a pruritic rash on her trunk and presented to an outside emergency department. The rash was noted to be vesicular and in a left truncal dermatomal distribution, not crossing midline. She was prescribed an unknown dose of valacyclovir for
... lacyclovir for presumed herpes zoster and discharged home. However, she was unable to tolerate any oral doses of valacyclovir at home due to nausea and she presented again the following day to the same emergency department for evaluation. A review of systems was positive for nausea, weakness, and myalgias, but negative for neck stiffness, fever, chills, vision change, numbness, as well as any respiratory, gastrointestinal, or genitourinary symptoms. A brain magnetic resonance imaging was performed and showed no abnormalities. Lumbar puncture (LP) was attempted but was unsuccessful due to patient discomfort. She was given intravenous (IV) fluids, ketorolac 15 mg IV, metoclopramide 10 mg IV, and morphine 2 mg IV, and subsequently transferred to the Massachusetts General Hospital for Children (MGHfC) for further evaluation. Initial examination at MGHfC revealed a tired, but nontoxic-appearing adolescent with vital signs appropriate for her age. Notably, she was afebrile. She had multiple intact vesicles on an erythematous base with areas of confluence in a T5 dermatomal distribution, from just below her left breast wrapping around to her back. There were no signs of bacterial superinfection with no purulent drainage. Her neurologic exam was overall unremarkable including a Keywords ► varicella-zoster virus vaccine ► varicella-zoster virus ► herpes zoster ► meningitis Abstract Since the adoption of the varicella-zoster virus (VZV) vaccine, the incidence of varicella infections of all types has declined. Although uncommon, local cutaneous herpes zoster secondary to vaccine-strain VZV has been well documented in healthy children. However, there are few reports of vaccine-strain VZV central nervous system disease in this same population. We present a case of a previously healthy twice-VZV vaccinated 14-year-old girl who presented with rash and headache who was found to have herpes zoster complicated by meningitis. Cerebrospinal fluid polymerase chain reaction confirmed zoster infection secondary to reactivation of vaccine-strain VZV. Her disease course and response to therapy are reviewed.