Summary about Disease
Varicella Zoster Meningitis (VZM) is a rare complication of varicella-zoster virus (VZV) infection. VZV is the virus that causes chickenpox (varicella) and shingles (herpes zoster). Meningitis refers to inflammation of the meninges, the membranes surrounding the brain and spinal cord. In VZM, VZV infects the meninges, leading to inflammation and neurological symptoms. It can occur during or after a chickenpox or shingles outbreak, or even without a visible rash (zoster sine herpete).
Symptoms
Symptoms of VZM can vary in severity and may include:
Headache (often severe)
Fever
Stiff neck
Photophobia (sensitivity to light)
Nausea and vomiting
Altered mental status (confusion, disorientation, drowsiness)
Seizures
Rash (may or may not be present, depending on if shingles or chickenpox is present)
Neurological deficits (weakness, sensory changes)
Causes
VZM is caused by the varicella-zoster virus (VZV) infecting the meninges. The virus may spread to the central nervous system (CNS) via the bloodstream or along cranial nerves. Reactivation of latent VZV (from a prior chickenpox infection) is a common cause, especially in the elderly or immunocompromised. Primary infection, although rare, can also lead to VZM.
Medicine Used
The primary treatment for VZM is antiviral medication, typically administered intravenously. Common antiviral medications include:
Acyclovir
Valacyclovir
Foscarnet (used in acyclovir-resistant cases) Supportive care, such as pain management, anti-seizure medication (if needed), and management of complications (e.g., cerebral edema), are also crucial.
Is Communicable
VZV is communicable. A person with active chickenpox or shingles (if rash is present) can transmit the virus to someone who has never had chickenpox or the chickenpox vaccine. However, VZM itself is not directly communicable. It's the underlying VZV infection (chickenpox or shingles) that's contagious. The risk of transmission from a VZM patient is lower since it's typically associated with shingles, which has a lower transmission rate than chickenpox and require direct contact with the vesicles.
Precautions
Precautions to prevent the spread of VZV include:
Vaccination: The varicella vaccine (for chickenpox) and the recombinant zoster vaccine (RZV, Shingrix) for shingles are highly effective in preventing infection and reactivation, respectively.
Avoid Contact: Avoid close contact with individuals who have active chickenpox or shingles, especially pregnant women, newborns, and immunocompromised individuals.
Hygiene: Practice good hygiene, including frequent handwashing.
Cover Rash: If you have shingles, keep the rash covered to prevent spreading the virus.
Isolation: Individuals with active chickenpox or disseminated shingles should be isolated until the lesions have crusted over.
How long does an outbreak last?
The duration of a VZM outbreak is dependent on the individuals immune response, however:
Chickenpox: A chickenpox outbreak typically lasts for 5-10 days.
Shingles: A shingles outbreak typically lasts for 2-4 weeks.
Postherpetic neuralgia (PHN), chronic pain following a shingles outbreak, can persist for months or even years.
Varicella Zoster Meningitis: The meningitis component can last days to weeks with proper treatment.
How is it diagnosed?
Diagnosis of VZM typically involves:
Clinical Evaluation: Assessing the patient's symptoms and medical history.
Lumbar Puncture (Spinal Tap): Analyzing cerebrospinal fluid (CSF) for:
Elevated white blood cell count (lymphocytic pleocytosis)
Elevated protein levels
Normal or slightly decreased glucose levels
VZV DNA detection by polymerase chain reaction (PCR)
Neuroimaging (MRI or CT Scan): To rule out other causes of meningitis or encephalitis, and to assess for complications.
VZV Antibody Testing: Blood tests may be used to detect VZV-specific antibodies, but they are less helpful in acute diagnosis compared to CSF PCR.
Timeline of Symptoms
The timeline of symptoms can vary:
Prodromal Phase: (1-2 days before rash in shingles, several days before rash in chickenpox): Fever, headache, malaise.
Rash Onset:
Chickenpox: Generalized, itchy rash that progresses from macules to papules to vesicles to pustules to crusts.
Shingles: Painful, localized rash that follows a dermatomal distribution (a specific nerve pathway). Vesicles develop, break open, and crust over.
Meningitis Symptoms: Meningitis symptoms can appear concurrently with or after the rash. It can even occur without a rash (zoster sine herpete).
Resolution: With antiviral treatment, symptoms typically improve within a few days to weeks. However, neurological deficits may persist in some cases.
Important Considerations
Immunocompromised Individuals: VZM is more common and severe in individuals with weakened immune systems (e.g., HIV/AIDS, organ transplant recipients, those on immunosuppressive medications).
Prompt Treatment: Early diagnosis and treatment with antiviral medications are crucial to improve outcomes and reduce the risk of complications.
Complications: Potential complications of VZM include:
Encephalitis (brain inflammation)
Myelitis (spinal cord inflammation)
Cranial nerve palsies
Seizures
Stroke
Permanent neurological deficits
Death (rare)
Differential Diagnosis: It is important to differentiate VZM from other causes of meningitis, such as bacterial or other viral infections.
Vaccination: Vaccination against varicella and herpes zoster is the best way to prevent VZV infection and its complications, including meningitis.