A rare case of disseminated varicella-zoster with acute encephalitis in a patient with polysubstance use disorder

SESSION TITLE: Critical Care Case Report Posters 44 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Varicella-zoster encephalitis is an uncommon complication of herpes zoster (1 in 33,000–50,000 cases). Immunosuppression is a risk factor for disseminated herpes zoster and encephalitis, but it may also be seen in immunocompetent patients. Typically, it presents with delirium within days following vesicular eruptions. It may also occur before the onset of rash or after an episode of herpes zoster. Due to its low incidence, the diagnosis is often missed. We present a case of disseminated herpes-zoster with acute encephalitis in a patient with polysubstance use disorder initially treated for alcohol withdrawal. CASE PRESENTATION: A 63-year-old male with a history of polysubstance and alcohol use disorder was brought in by emergency medical service from a train station for possible drug use. He had a witnessed grand mal seizure in the emergency department and was intubated for hypercapnic respiratory failure. Blood alcohol level was high and urine toxicology screen was positive for cocaine, opiates, and cannabis. Computed tomography of the head showed no acute process. Next day, the patient self-extubated. However, the patient was delirious without any focal neurological deficit and was managed with benzodiazepines for alcohol withdrawal syndrome. On day 6, though still confused, he was noted to have scattered vesicular lesions on the left lateral thigh and back along the L3 and L4 dermatomal distributions. A lumbar puncture showed clear fluid, a white blood cell count of 4 cells/mcL, protein of 83 mg/dL, the glucose of 70 mg/dL, and a red blood cell count of 438 cells/mcL. Intravenous acyclovir was started, and the patient's mental status started to improve gradually. Later, HSV-1 and 2 DNA returned negative, but varicella-zoster virus DNA returned positive. His HIV test was negative. The patient completed 14 days of intravenous acyclovir and was discharged home without any neurological deficit. DISCUSSION: Our patient initially presented with drug use and seizure, was being treated for alcohol withdrawal without much improvement, and was later found to have scattered vesicular lesions on the left lateral thigh and back along the L3 and L4 dermatomal distributions. Careful physical examination may play an important role in leading to a diagnosis of varicella-zoster encephalitis.Treatment for varicella-zoster virus encephalitis is intravenous acyclovir for 10 to 14 days. CONCLUSIONS: It is important to consider varicella-zoster encephalitis in the differential diagnosis of mental status change with or without a vesicular rash. A lumbar puncture should be considered to rule out meningoencephalitis, and treatment should be started promptly. REFERENCE #1: Varicella and herpes zoster vaccines: WHO position paper, June 2014. Wkly Epidemiol Rec. 2014;89(25):265-287. REFERENCE #2: Jemsek J, Greenberg SB, Taber L, Harvey D, Gershon A, Couch RB. Herpes zoster-associated encephalitis: clinicopathologic report of 12 cases and review of the literature. Medicine (Baltimore). 1983;62(2):81-97. REFERENCE #3: Tunkel AR, Glaser CA, Bloch KC, et al. The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2008;47(3):303-327. doi:10.1086/589747. DISCLOSURES: No relevant relationships by Htun Aung No relevant relationships by Amulya Bellamkonda No relevant relationships by Danilo Enriquez No relevant relationships by Aneeta Kumari No relevant relationships by Aye Thida No relevant relationships by Aung Ya No relevant relationships by John Zeibeq