Disseminated Varicella Zoster in a 92 Year Old

We describe an unusual case of Varicella zoster virus (VZV) in an otherwise well 92 year old. Presentation was following a fall and confusion, which had developed over two days. She had a Glasgow coma scale score of 11 and was confused. She had generally increased tone. There was a coalescing vesicular rash on the left side of her chest in a T6-8 dermatomal distribution. There were further vesicles on the trunk which were spreading. An initial diagnosis of ‘shingles’ with confusion of unclear cause was made. She was dehydrated as she had been vomiting and there was slight hyponatraemia, thought to be due to concurrent medications. CT head showed no acute abnormalities. Lumbar puncture revealed a lymphocytosis with mildly elevated protein and low glucose. Based on this she was treated with antiviral and broad-spectrum antibiotic medications. These were modified to intravenous acyclovir only following confirmation of positive PCR test for varicella zoster virus from the CSF. The rash improved and wakefulness returned over the following two weeks. The patient remained dependent and confused, having previously been living alone independently.

VZV is a common pathogen, but in this case presented in its rare disseminated form, with meningoencephalitis and widespread cutaneous involvement. Disseminated VZV has been previously described but usually occurs in patients known to be immunocompromised. Our case demonstrates that supposedly healthy patients, especially the elderly, are at risk of this condition and it should be considered as a diagnosis in the presence of a rash and confusion.