Varicella-zoster meningitis in immunocompetent adults: A case series and literature review.

Background: Varicella-zoster virus (VZV) meningitis in immunocompetent adults is uncommon and can present atypically, sometimes mimicking raised intracranial pressure or occurring with minimal rash. We report a case series highlighting this spectrum and practical diagnostic points.

Case presentations: Three immunocompetent adults (71-year-old man, 35-year-old woman, 52-year-old woman) presented primarily with headache and variable cutaneous findings: Case 1: Painful C5-C6 zoster followed by flaccid proximal right arm weakness; MRI brachial plexus showed inflammatory radiculoplexus involvement consistent with segmental zoster paresis. CSF demonstrated lymphocytic pleocytosis and was VZV PCR-positive. Case 2: Severe headache with papilledema mimicking idiopathic intracranial hypertension; CSF showed lymphocytic meningitis with positive VZV PCR. Case 3: Mild headache with a scant forehead lesion; CSF revealed lymphocytic pleocytosis and VZV PCR positivity. All patients received intravenous acyclovir with oral step-down where appropriate. No antiviral-related adverse effects were documented.

Outcomes: Clinical recovery was favourable in all three cases; Case 1 showed proximal strength improvement on follow-up, and Cases 2 and 3 had resolution of symptoms by discharge. A brief literature review (1997-2023) underscores that VZV meningitis can occur in immunocompetent hosts and may present without a classic rash.

Conclusions: VZV meningitis should be considered in the differential diagnosis of aseptic meningitis and raised intracranial pressure syndromes in immunocompetent adults. Early lumbar puncture with CSF PCR facilitates timely antiviral therapy and good outcomes.