Varicella-zoster Virus Meningitis Besides Bacterial Otitis

An 80-year-old man with a 10-day history of right-sided otalgia presented with a fever and coma. He had a history of surgery for gastric cancer and hepatocellular carcinoma and was receiving oral medication for diabetes. The patient exhibited neck stiffness, external otitis symptoms, and otorrhea (Picture A). Thus, we immediately initiated empirical therapy for bacterial meningitis after obtaining a blood culture sample. However, shingles near the area affected by otitis were evident (Picture B), prompting the addition of acyclovir. A cerebrospinal fluid analysis revealed mononuclear pleocytosis (131 /μL), with a slight decrease in glucose levels. The use of the FilmArray meningitis panel^Ⓡ (1) and brain magnetic resonance imaging (Picture C; gadolinium-enhanced fluid-attenuated inversion recovery) facilitated a rapid diagnosis of varicella-zoster virus (VZV) meningoencephalitis along with bacterial otitis (Staphylococcus aureus grew in the exudate culture). The patient's consciousness level improved five days after admission. A systematic skin examination focusing on more than just prominent rashes is crucial. Identifying a bacterial infection does not exclude the possibility of a viral infection. In addition, bacterial external otitis is often secondary to or occurs concurrently with other disorders. Thus, clinicians should take note that neurological symptoms coexisting with bacterial external otitis can potentially be attributed to VZV infection (2); within such VZV cases, there is a rare potential for progression towards meningoencephalitis, as observed in our case.

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The authors state that they have no Conflict of Interest (COI).