We report a case of decreased cerebrospinal fluid glucose with lymphocytic pleocytoisis in a patient with herpes zoster meningoencephalitis. The finding was likely to be confused with that of tuberculous meningoencephalitis. The concentration of CSF glucose is a critical point in the differential diagosis of various causes of nervous system infection. Although the herpes zoster meningoencephalitis isa well recognized, cases with markedly low, level of CSF glucose has been rare. We reviewed such unusual cases in the literature that were accompanied by hypoglycorrhachia. The duration of hypoglycorrhachia was transient. This suggests a differential point from that of tuberculous meningitis.
Cerebrospinal Fluid ; Encephalitis, Varicella Zoster* ; Glucose* ; Herpes Zoster* ; Humans ; Meningoencephalitis ; Nervous System ; Tuberculosis, Meningeal

Herpes zoster can be associated with a number of neurologic complications but meningoencephalitis with herpes zoster is rarely seen. We report a case of herpes zoster ophthalmicus followed by the meningoencephalitis, which developed during treatment with acyclovir infusion. A 73-year-old male patient developed a fever and mental confusion on the third day of the treatment. Neurological examination revealed neck stiffess, increased deep tendon reflex and positive Babinski sign. The cerebrospinal fluid examination revealed increased opening pressure, increased protein and a lymphocytic pleocytosis. The glucose level was decreased, which is a very unusual feature in viral meningoencephalitis.
Acyclovir ; Aged ; Cerebrospinal Fluid ; Encephalitis, Varicella Zoster ; Fever ; Glucose ; Herpes Zoster Ophthalmicus ; Herpes Zoster* ; Humans ; Leukocytosis ; Male ; Meningoencephalitis ; Neck ; Neurologic Examination ; Reflex, Babinski ; Reflex, Stretch

OBJECTIVES: Varicella-zoster virus (VZV) is one of the most common etiologies of viral meningitis/encephalitis. The early clinical manifestations and cerebrospinal fluid (CSF) changes of VZV meningitis/encephalitis lack specificity, and it is easy to be misdiagnosed as other viral encephalitides or tuberculous meningitis. This study aims to investigate whether the clinical characteristics, CSF analysis findings, and CSF cytokine levels could distinguish VZV meningitis/encephalitis from central nervous system (CNS) herpes simplex virus (HSV) and Mycobacterium tuberculosis (MTB) infections. METHODS: The medical records from 157 CNS infections, including 49 HSV (45 HSV-1, 4 HSV-2), 55 VZV, and 53 MTB infections between January 2018 and June 2021 in the Cytology Laboratory, Department of Neurology, Third Xiangya Hospital of Central South University were retrospectively reviewed. The data of 3 groups included demographic characteristics, laboratory results, radiographic findings, and outcomes. The levels of 12 cytokines (IL-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-17, IFN-γ, IFN-α, and TNF-α) in the CSF of 68 patients (13 HSV, 22 VZV, and 33 MTB infection cases) were quantified. Clinical and laboratory data were compared among the 3 groups. RESULTS: The most common clinical manifestations in the 3 groups were fever, headache, vomiting, and neck stiffness. The clinical manifestations of HSV and VZV CNS disease were similar, although fever and altered consciousness were less common in the VZV group than those in the HSV and MTB groups (63.6% vs 87.8% vs 96.2%, P<0.001, and 14.5% vs 26.5% vs 47.2%, P=0.004, respectively). Seven patients (7/55, 12.7%) presented cutaneous zoster in the VZV group. CSF leukocyte count was significantly higher in the VZV group (230×10⁶ cells/mL) and MTB groups (276×10⁶ cells/mL) than that in the HSV group (87×10⁶ cells/mL, P=0.002). CSF protein level was significantly higher in the VZV than that in the HSV group (1 034 mg/L vs 694 mg/L, P=0.011) but lower than that in the MTB group (1 744 mg/L, P<0.001). IL-6 (VZV vs HSV vs MTB: 2 855.93 pg/mL vs 2 128.26 pg/mL vs 354.77 pg/mL, P=0.029) and IL-8 (VZV vs HSV vs MTB: 4 001.46 pg/mL vs 1 578.11 pg/mL vs 1 023.25 pg/mL, P=0.046) levels were significantly different among the 3 groups and were elevated in the VZV group.Post hoc analysis revealed that IL-6 and IL-8 were significantly higher in the VZV group than those in the MTB group (P=0.002 and P=0.035, respectively), but not in the HSV group (P>0.05). CONCLUSIONS VZV meningitis/encephalitis presents with CSF hypercellularity and proteinemia, challenging the classical view of CSF profiles in viral encephalitis. CSF IL-6 and IL-8 levels are elevated in patients with VZV meningitis/encephalitis, indicating a more intense inflammatory response in these patients.
Humans ; Central Nervous System Infections ; Encephalitis ; Encephalitis, Varicella Zoster/diagnosis* ; Encephalitis, Viral/diagnosis* ; Herpesvirus 3, Human ; Interleukin-6 ; Interleukin-8 ; Meningitis ; Retrospective Studies

BACKGROUND: Herpes zoster meningoencephalitis is a rare neurological complication and the known risk factors include an immunocompromised status, infiltration into the trigeminal ganglion, disseminated herpes zoster and elderly patients. Serious complications may develop, including cerebral hemorrhage. OBJECTIVE: As early diagnostic detection is mandatory to prevent long-term sequelae, we wanted to determine what signs and symptoms we should focus on for diagnosing zoster meningoencephalitis at an early stage. We also investigated the descriptive statistics of the patients and compared them with the patients who had non-complicated herpes zoster. METHODS: We examined the medical records of 5114 herpes zoster patients who had visited our clinic from 1996 through 2009. Among them, 18 patients who were diagnosed with herpes zoster meningoencephalitis by cerebrospinal fluid tests were subject to examinations to assess the incidence rates, the age distribution, the ganglion distribution, the clinical aspects, the underlying diseases and the presence of complications. RESULTS: The ages of the patients with herpes zoster meningoencephalitis showed that 50% of the patients were under 30 years old. Infiltration into the trigeminal ganglion and immunocompromising underlying diseases accounted for 50% and 16.7% of the total patients, respectively. In the case of disseminated herpes zoster patients, no meningoencephalitis developed. The rates of neck stiffness and fever, which are the most common symptoms of meningoencephalitis, were lower in the patients with herpes zoster meningoencephalitis (33.3% and 11.1%, respectively). However, headaches accompanied with nausea or vomiting showed high sensitivity (88.9%), and a high positive predictive value (69.6%) (p<0.001). All the patients were treated with acyclovir for 10~14 days, and cerebral hemorrhage occurred in 1 of them (5.5%) after treatment. CONCLUSION: When a patient with herpes zoster has symptoms of headache and nausea or vomiting then herpes zoster meningoencephalitis should be considered even if neck stiffness and fever are not present.
Acyclovir ; Age Distribution ; Aged ; Cerebral Hemorrhage ; Encephalitis, Varicella Zoster ; Fever ; Ganglion Cysts ; Headache ; Herpes Zoster ; Humans ; Incidence ; Medical Records ; Meningoencephalitis ; Nausea ; Neck ; Risk Factors ; Trigeminal Ganglion ; Vomiting

BACKGROUND: Herpes zoster meningoencephalitis is a rare neurological complication and the known risk factors include an immunocompromised status, infiltration into the trigeminal ganglion, disseminated herpes zoster and elderly patients. Serious complications may develop, including cerebral hemorrhage. OBJECTIVE: As early diagnostic detection is mandatory to prevent long-term sequelae, we wanted to determine what signs and symptoms we should focus on for diagnosing zoster meningoencephalitis at an early stage. We also investigated the descriptive statistics of the patients and compared them with the patients who had non-complicated herpes zoster. METHODS: We examined the medical records of 5114 herpes zoster patients who had visited our clinic from 1996 through 2009. Among them, 18 patients who were diagnosed with herpes zoster meningoencephalitis by cerebrospinal fluid tests were subject to examinations to assess the incidence rates, the age distribution, the ganglion distribution, the clinical aspects, the underlying diseases and the presence of complications. RESULTS: The ages of the patients with herpes zoster meningoencephalitis showed that 50% of the patients were under 30 years old. Infiltration into the trigeminal ganglion and immunocompromising underlying diseases accounted for 50% and 16.7% of the total patients, respectively. In the case of disseminated herpes zoster patients, no meningoencephalitis developed. The rates of neck stiffness and fever, which are the most common symptoms of meningoencephalitis, were lower in the patients with herpes zoster meningoencephalitis (33.3% and 11.1%, respectively). However, headaches accompanied with nausea or vomiting showed high sensitivity (88.9%), and a high positive predictive value (69.6%) (p<0.001). All the patients were treated with acyclovir for 10~14 days, and cerebral hemorrhage occurred in 1 of them (5.5%) after treatment. CONCLUSION: When a patient with herpes zoster has symptoms of headache and nausea or vomiting then herpes zoster meningoencephalitis should be considered even if neck stiffness and fever are not present.
Acyclovir ; Age Distribution ; Aged ; Cerebral Hemorrhage ; Encephalitis, Varicella Zoster ; Fever ; Ganglion Cysts ; Headache ; Herpes Zoster ; Humans ; Incidence ; Medical Records ; Meningoencephalitis ; Nausea ; Neck ; Risk Factors ; Trigeminal Ganglion ; Vomiting

BACKGROUND: Many studies about herpes zoster are available in Korean dermatological literature. However, only a few of them reported herpes zoster meningoencephalitis. OBJECTIVE: The aim of this study was to determine the epidemiology and clinical features of herpes-zoster meningoencephalitis compared with herpes zoster without meningoencephalitis. METHODS: We examined the medical records of 3,154 patients with herpes zoster, who had visited our hospital from January 2008 to March 2016. Among them, 159 patients underwent cerebrospinal fluid analysis. Fifty-one patients who were diagnosed with herpes zoster meningoencephalitis and the 3,103 patients who were without meningoencephalitis were subjected to examinations to assess the incidence rates, the age distribution, the ganglion distribution, severity of acute pain, postherpetic neuralgia, serum VZV IgM and IgG, the clinical aspects, the underlying diseases, and the presence of complications. RESULTS: The rate of herpes zoster meningoencephalitis was 1.61%, with a mean age of 53.95 years, and the female-to-male patient ratio was 1.68. The trigeminal nerve was the most frequently involved dermatome (53.7%), with the ophthalmic branch (V1) involved at a rate of 68.96% among them. The serum VZV IgM was significantly higher in herpes zoster meningoencephalitis compared with herpes zoster without meningoencephalitis. Dizziness, mental change, palsy, and myalgia with nausea/vomiting showed high predictive values. All the patients were treated with acyclovir for 10~14 days, and 1 of them expired (1.96%). CONCLUSION: The results of this study demonstrated that herpes-zoster meningoencephalitis was associated with high serum levels of VZV IgM compared with herpes zoster without meningoencephalitis. When a patient with herpes zoster has symptoms of headache and nausea/vomiting with dizziness, mental status change, palsy, or myalgia, herpes-zoster meningoencephalitis should be considered.
Acute Pain ; Acyclovir ; Age Distribution ; Cerebrospinal Fluid ; Dizziness ; Encephalitis, Varicella Zoster ; Epidemiology* ; Ganglion Cysts ; Headache ; Herpes Zoster ; Humans ; Immunoglobulin G ; Immunoglobulin M ; Incidence ; Medical Records ; Meningoencephalitis* ; Myalgia ; Neuralgia, Postherpetic ; Paralysis ; Trigeminal Nerve