DISSEMINATED VZV SEIZURE IN AN IMMUNOCOMPETENT YOUNG MALE WITH UNCONTROLLED DIABETES

Document Type

Conference Proceeding

Publication Date

6-27-2024

Publication Title

J Gen Intern Med

Keywords

aciclovir, ceftriaxone, creatine kinase, isophane insulin, lactic acid, protamine, troponin, valaciclovir, vancomycin, acidosis, aged, bipolar disorder, case report, chickenpox, clinical article, conference abstract, dermatome, diabetes mellitus, diabetic patient, diagnosis, drug therapy, electroencephalogram, electroencephalography, emergency ward, epilepsy, herpes zoster, HIV test, human, human cell, hyperglycemia, intravenous drug administration, leukocytosis, lumbar puncture, lymphocytosis, male, MRI scanner, nuclear magnetic resonance imaging, oral drug administration, physical examination, pleocytosis, risk factor, schizophrenia, seizure, sinus tachycardia, skin manifestation, special situation for pharmacovigilance, thoracic spine, Varicella zoster virus, vesicular rash, vomiting

Abstract

CASE: A 39-year-old male with a history of untreated schizophrenia and bipolar disorder presented with a witnessed seizure, characterized by extremity shaking, unresponsiveness, and vomiting, lasting 10 minutes. He reports a prior seizure-like episode one year ago but was never medically evaluated. Upon arrival at the emergency department, he exhibited sinus tachycardia, elevated troponins peaking at 54, and hyperglycemia at 418 mg/dL. HIV testing was negative, and the patient had no recent illnesses or trauma. Labs were pertinent for an increased lactate of 3.9, anion gap metabolic acidosis, elevated CPK at 456, and leukocytosis of 19.7. Physical exam was notable for a single dermatome vesicular rash on the right thoracic spine. Given the clinical picture concerning for meningitis, a lumbar puncture (LP) was performed, and the patient was empirically initiated on vancomycin, acyclovir, and ceftriaxone. Further workup revealed A1C of 15.0. EEG and MRI were unremarkable at the time for epileptic or ischemic changes respectively. A diagnostic LP demonstrated pleocytosis, lymphocytosis and confirmed Varicella-Zoster Virus (VZV). Treatment with IV acyclovir resulted in clinical improvement, and he was discharged following a 7-day course with neutral protamine Hagedorn (NPH) insulin (4 units twice per day) and 7 days of oral valacyclovir. IMPACT/DISCUSSION: This case challenges the conventional understanding of disseminated (VZV), typically observed in immunocompromised individuals. The patient is a young male with no apparent risk factors, presenting with a seizure and vesicular lesions across only a single dermatome as manifestations of disseminated zoster. Notably, there exists a few cases that link disseminated VZV and diabetes and only one involving one single dermatome in an immunocompetent diabetic patient, involving the abdomen in that case. In this patient, the possibility of meningeal involvement is significant, despite limited dermatomal spread. This may potentially be explained by untreated hyperglycemia resulting in compromised immunity. However other case reports highlighted this association in patients with well controlled diabetes. Patients with diabetes are thought to be at an increased risk as studies has show lower cell-mediated immunity in these patients against VZV. Given the necessity for airborne precautions in disseminated zoster, it is crucial to promptly identify criteria for disseminated zoster as early recognition may improve infection control. CONCLUSION: A high suspicion of disseminated herpes zoster in patients with diabetes should be considered. It is crucial to promptly identify visceral involvement as disseminated zoster, even in cases with limited cutaneous manifestation, in order to limit risk of infectious transmission. Recognize the criteria for disseminated varicella zoster virus (VZV) infection, emphasizing that visceral involvement should be considered, even in cases with limited dermatome manifestation.

Volume

39

First Page

S291

Last Page

S292

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