Herpes zoster ophthalmicus with concurrent HSV/VZV meningitis

Herpes zoster ophthalmicus (HZO) is a potentially vision-threatening reactivation of varicella zoster virus involving the ophthalmic branch of the trigeminal nerve. Immunocompromised patients are at higher risk for complications, including keratitis, vision loss, and central nervous system (CNS) involvement. We present a case of HZO in an immunocompromised female with metastatic breast cancer and multiple comorbidities, who developed keratoconjunctivitis, preseptal cellulitis, and concurrent HSV-1 and VZV meningitis, which is exceedingly rare. Lumbar puncture confirmed co-infection of the CNS. Notably, the patient developed permanent vision loss despite early initiation of antiviral therapy. The case highlights the importance of prompt recognition and a low threshold for escalating treatment in patients with disorientation and neurological symptoms, as well as the need for vaccination, especially in at-risk patient groups.