Varicella reactivation presenting as shingles and aseptic meningitis in an immunocompetent 11-year-old boy

Varicella-Zoster Disease of the Central Nervous System in Immunocompetent Children: Case Series and a Scoping Review

BACKGROUND

Varicella-Zoster Virus (VZV) is characterized by its ability to enter a dormant state within the body. When the wild or vaccine virus reactivates, it can lead to herpes zoster (HZ), which infrequently manifests as a neuroinfection.

OBJECTIVES

The aim of the study was to analyze the clinical manifestations and outcomes associated with VZV reactivation in the CNS in immunocompetent children.

METHODS

We searched medical databases for case reports using the keywords "zoster", "meningitis", "encephalitis", and "immunocompetent". The inclusion criteria were age below 18 years, any gender, race, and ethnicity, no features or history of immunodeficiency, and confirmation of VZV reactivation through the detection of VZV DNA in the CSF. Patients were categorized into two groups: children experiencing the reactivation of the wild virus and children with the vaccine strain virus.

RESULTS

The cohort included six children hospitalized in our hospital and 49 children reported in the literature. In 37 (67%), a wild-type virus was detected, while in 18 (33%), an infection was caused by the vaccine strain. There were no differences in the clinical presentation between the two groups. A typical rash was observed in 32 (58%) children. Approximately 41 of the 55 children (75%) received antiviral treatment. Four patients experienced complications.

CONCLUSIONS

Neither a history of VZV immunization nor the absence of a skin rash can definitively exclude VZV meningitis. It is important to note that any seemingly healthy child, regardless of recognized risk factors, could develop HZ meningitis.

Primary varicella zoster infection compared to varicella vaccine reactivation associated meningitis in immunocompetent children

We diagnosed varicella zoster virus (VZV) meningitis in a healthy adolescent boy who presented without a rash or fever. We aim to compare VZV reactivation meningitis in children after primary VZV infection and VZV vaccination. We reviewed the literature up until June 2020 using Pubmed/MEDLINE and EMBASE databases using 'varicella zoster', 'meningitis' and 'children' as keywords. Only English articles were included. Twenty-five cases were included in this review. Children who had VZV reactivation meningitis after vaccination were younger (7 ± 3.4 years vs. 11.9 ± 3.6 years, P = 0.0038), had a shorter interval between first exposure to reactivation (5.6 ± 2.9 years vs. 8.8 ± 3.2 years, P = 0.018) and more likely to have a rash (100% vs. 55%, P = 0.04). VZV reactivation meningitis occurs after both primary VZV infection and VZV vaccination. The absence of exanthem, fever or meningism does not rule out VZV meningitis.