Disseminated herpes zoster with acute encephalitis in an immunocompetent elderly man

A retrospective observational study on disseminated herpes zoster in immunocompetent patients

INTRODUCTION

Disseminated herpes zoster (DHZ) is a severe infection associated with high incidences and mortality rates in immunocompromised patients. Although studies have shown its occurrence in immunocompetent patients, its epidemiology, clinical presentation, and treatment outcomes in this cohort remain unknown. Thus, this study aimed to examine the clinical presentation, treatment, complications, and outcomes of DHZ in immunocompetent patients and compare these findings with previous studies.

METHODS

We included 20 immunocompetent patients of DHZ at our institution and reviewed 42 previously published cases. We then investigated the clinical features, predisposing factors, laboratory findings, treatment, and outcomes of all cases including in-hospital mortality, neurological dysfunction at discharge, and postherpetic neuralgia. We compared DHZ-immunocompetent patients to DHZ-immunocompromised patients.

RESULTS

Patients had a median age of 71.5 years and were predominantly male. The trigeminal area was the most common site of initial rash, with a mean dissemination time of 6.5 days. Pain was the most common symptom, followed by fever (approximately 40 % of cases); acyclovir was the most used treatment. Additionally, the in-hospital mortality was 0 %, neuropathy at discharge was observed in approximately 10 % of patients, and postherpetic neuralgia was present in approximately 40 % of patients. In the immunocompromised cases, the mortality rate was 12 %, which was higher than in our cases; however, the rates of neuropathy and postherpetic neuralgia were lower.

CONCLUSIONS

This study provides new insights into the clinical presentation, treatment, and outcomes of DHZ cases in immunocompetent patients, highlighting its tendency for residual neurological damage despite having low mortality rates.

Disseminated Zoster Involving the Whole Body in an Immunocompetent Patient Complaining of Left Leg Radiating Pain and Weakness: A Case Report and Literature Review

Introduction

Disseminated herpes zoster is defined as at least 20 skin lesions in multiple dermatomes. In particular, it has been reported mainly in patients with immunological defects. To our knowledge, there is no reported case of disseminated zoster in a non-immunocompromised patient with leg radiating pain and weakness.

Case presentation

A 74-year-old man visited our hospital with left leg radiating pain and left hip pain. He had no underlying disease other than hypertension. Neurologic examination revealed radiating pain on the L4 dermatome of the left leg. The muscle power was grade 3 for the hip flexor and knee extensor, and grade 4 for the ankle dorsiflexor and big toe dorsiflexor of the left leg. There were no sensory changes or skin lesions on his left leg. Herniation of the nucleus pulposus of the lumbar spine was suspected and lumbar magnetic resonance imaging (MRI) was performed. However, no pathologic lesions were seen on lumbar MRI. On the third day of hospitalization, erythematous patches and vesicles were observed on the head, face, ear, neck, trunk, back, and both lower extremities. Herpes zoster infection was confirmed by polymerase chain reaction analysis. Treatment was performed with 250 mg of intravenous acyclovir every 8 hours for 6 days and 62.5 mg of intravenous methylprednisolone for 4 days. On the 13th day of hospitalization, the skin lesions and left leg radiating pain and weakness improved.

Conclusion

We report the first case of disseminated herpes zoster involving the whole body in a non-immunocompromised patient complaining of left leg radiating pain and weakness. After treatment, both the patient's radiating pain and weakness improved.

Global magnitude of encephalitis burden and its evolving pattern over the past 30 years

OBJECTIVE

We aimed to estimate the spatiotemporal patterns of the encephalitis burden along with its attributable risk factors at the national, regional, and global levels, which may be helpful in guiding targeted prevention and treatment programs.

METHODS

Based on available data sources, the incidence, mortality, and disability-adjusted life years (DALYs) of encephalitis in 204 countries and regions from 1990 to 2019 were reconstructed by the Global Burden of Disease Study 2019 using the Cause of Death Ensemble model, spatiotemporal Gaussian process regression, and DisMod-MR 2.1. We conducted a systematic analysis on the epidemiological characteristics of encephalitis in detail by gender, region, and age over the past three decades.

RESULTS

Globally, 1,444,720 incident cases, 89,900 deaths, and 4.80 million DALYs related to encephalitis were estimated in 2019. The age-standardized incidence rate and age-standardized mortality rate (ASMR) decreased from 23.17 and 2.18 to 19.33 and 1.19 per 100,000 person-years over the past 30 years, respectively. However, beginning in 2011-2013, the burden of encephalitis has shown an inflection point, with a further decline of the ASRs ceasing. Lower socio-demographic index (SDI) regions in South Asia, Western and Eastern Sub-Saharan Africa had the highest burden of encephalitis in 2019. During the past three decades, most countries of South Asia achieved significant control of the burden. In contrast, developed countries with a higher SDI have shown a notable increase in ASMR and age-standardized DALYs rate. Children and older adults have always been high-risk groups for encephalitis.

CONCLUSION

Although the global burden of encephalitis has decreased in the past 30 years, a further decline stopped from 2011-2013. The diverse burden in different regions calls for differentiated management, and the persistent high burden in some low-SDI regions and the increased burden in developed countries with higher SDIs deserve more attention.

ABBREVIATIONS

ASDR: age-standardized DALY rate, ASIR: age-standardized incidence rate, ASMR: age-standardized mortality rate, ASR: age-standardized rate, CI: confidence interval, DALY: disability-adjusted life-year, EAPC: estimated annual percentage change, GBD: Global Burden of Disease Study, HAP: household air pollution from solid fuels, HSE: herpes simplex encephalitis, HSV: herpes simplex virus, ICD: International Classification of Diseases, JE: Japanese encephalitis, PCR: polymerase chain reaction, SDI: socio-demographic index, TBE: tick-borne encephalitis, UI: uncertainty interval.

Late neurosyphilis and VZV meningoencephalitis coinfection

The incidence of syphilis has increasing recently, largely attributable to improved screening that may result in the diagnosis of chronic untreated infections. These patients can develop severe or subtle neurologic symptoms that can be missed and, therefore, detected accidentally while a patient is evaluated for other mimicking neurological infections. A 58-year-old man with diabetes presented with 2 days of aphasia, headache, chills and confusion. He had an MRI brain with evidence of a prior cerebrovascular accident. Subsequently, he developed a fever and thoracic dermatomal rash consistent with herpes zoster. A lumbar puncture was performed, and cerebrospinal fluid analysis revealed a lymphocytic pleocytosis, a reactive Venereal Disease Research Laboratory test and positive varicella-zoster virus (VZV) PCR. He was suspected to have both late neurosyphilis and acute meningoencephalitis from VZV. This paper will discuss how to approach the diagnosis of late neurosyphilis and possible associations with herpesvirus central nervous system infections.