Herpes Zoster Encephalitis: Diagnostic and Clinical Insights

Arputha Mary1, Nivetha2

1Assistant Nursing Superintend, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

2Staff Nurse, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

Abstract

Herpes Zoster encephalitis is a rare but serious complication of varicella-zoster virus (VZV) reactivation, leading to significant neurological morbidity if not identified early. This article presents a case report of Herpes Zoster encephalitis in an adult patient, highlighting the clinical features, diagnostic challenges, and management approaches.

Introduction

Herpes Zoster encephalitis is a rare but serious complication of varicella-zoster virus (VZV) reactivation, leading to significant neurological morbidity if not identified early. This article presents a case report of Herpes Zoster encephalitis in an adult patient, highlighting the clinical features, diagnostic challenges, and management approaches. This reactivation can present with fever, headache, altered mental status, neurological deficits or even seizures. Sometimes it can occur without a rash.

A person’s risk for Herpes Zoster and related complication, including hospitalization, sharply decreases after 50 years of age.

The incidence of Herpes Zoster ranges from 1.2 to 3.4 per 1000 persons per year among young healthy individuals. While incidence is 3.9 to 11.8 per 1000 persons per year among patients older than 65 years.

Case Presentation

A 38 year aged male, with Type II Diabetes Mellitus for 2 years on proper medication, presented to the emergency room with back pain, myalgia for 10 days, skin infection and high grade fever for 2 days. Patient received with irritability and respiratory distress, difficult to find the cause of the irritability.

Initial Workup

ECHO: Normal LV function, Valves structurally normal, IAS & IVS intact, normal chambers, nv thrombus / Vegetation / effusion / mass

Doppler Parameters

Trivial tricuspid regurgitation CTRPG – 26 mmHg

Normal Mitral, Aortic, and pulmonary valves

CT Scan Chest

Bilateral minimal pleural effusion with adjacent sub pleural collapse consolidation in postero basal segment of bilateral lower lobes.

Brain: No demonstrable intracranial lesion in MRI: (Plain and contrast with MRA and MRV), Cavum septum pellucidum present, contour size and shape of 4th, 3rd lateral ventricle are normal.

Nursing Assessment

Primary Survey

ABCDE assessment done.

  • A – On primary survey, the airway was clear.
  • B – Breathing was labored but not adequate. Emergency intubation was done after pre oxygenation with 15 Liters of O₂. SpO₂ reached 100%.
  • C – Circulation was normal with BP 100/60 mmHg
  • All peripheral pulses felt, and extremities were warm. But had tachycardia.
  • D – Pain score was 6/10 with severe back pain and myalgia. GCS was E1V1M4.
  • E- During physical assessment, staff noticed skin lesions on the patient thigh, timely recognition of these findings helped in reaching the proper diagnosis which could have been missed if the assessment were not done thoroughly.

Pre medication for intubation Inj. Midaz 2 mg IV stat, Inj. Fentanyl 100 mcg IV stat, Inj. Rocuronium 50 mg IV stat was given. Using a MAC-4 laryngoscope, cord visualization showed Grade C-L I. An ET tube size 8.0 was inserted and fixed at 22 cm at the right angle of mouth.

Impression

New onset seizure, Herpes zoaster encephalitis and Aspiration pneumonia.

Emergency Nursing Intervention

Vital signs were closely monitored and documented. Neurological status was assessed regularly, including GCS scoring, pupil reactions, and seizure activity. Intake–output charting was maintained throughout hospitalization.

Therapeutic Interventions

Oxygen therapy was administered with ventilator support as indicated by the physician.  Intravenous fluids were infused as prescribed, with strict monitoring.

Antiviral medications (Acyclovir), analgesics, and anticonvulsants were administered as ordered.

Positioning and Comfort

The patient was positioned in semi-fowler’s position to promote comfort and ease of breathing. Pain level was monitored, and comfort measures were provided. Pressure-relieving measures were implemented, including the use of an air mattress and re-positioning every two hours.

Skin and Infection Care

Skin assessments were performed in each shift. The rash area was observed for signs of secondary infection and managed as protocol.

Nutrition and Hydration

Nutritional needs were supported with adequate diet and fluid intake. Hydration status was monitored and maintained.

Family Education and Support

The patient’s family was educated about the condition, treatment plan and importance of adherence. Emotional support was provided to both patient and family during illness.

Conclusion

Patient was discharged in stable conditions within a week. Antiviral medications can help shorten the duration and severity of the outbreak, especially if treatment started within 72 hr of the rash appearing.

HZE presents with variable, nonspecific symptoms that can mimic other forms of encephalitis, making early diagnosis and treatment crucial, especially in older or immunocompromised individuals. The condition often requires definitive diagnosis through cerebrospinal fluid (CSF)/navVZV PCR testing, and prompt antiviral treatment with intravenous acyclovir can significantly improve neurological function, though some patients may experience lasting deficits.

Reference

  • Gilden DH, Kleinschmidt-DeMasters BK, LaGuardia JJ, Mahalingam R, Cohrs RJ. Neurologic complications of the reactivation of varicella-zoster virus. N Engl J Med. 2000;342(9):635–45. doi: 10.1056/NEJM200003023420906.
  • Grahn A, Studahl M. Varicella-zoster virus infections of the central nervous system – Prognosis, diagnostics, and treatment. J Infect. 2015;71(3):281–93. doi: 10.1016/j.jinf.2015.06.004.
  • Science M, Macgregor D, Richardson SE, Mahant S, Tran D, Bitnun A. Central nervous system complications of varicella-zoster virus. J Pediatr. 2014;165(4):779–85. doi: 10.1016/j.jpeds.2014.06.014.

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