International Journal of

Case Report
Dermatology and Venereology
OPEN

Viral Encephalitis Caused by Herpes Zoster

in the Waist and Abdomen: An Unusual
Case Report
Jian-Xia Chen, Yan-Yan Feng∗, Xiao-Jing Kang∗
Department of Dermatology, People’s Hospital of Xinjiang Uygur Autonomous Region, Uygur, Xinjiang 830001, China.

Introduction status, cranial nerve reflexes, and motor and sensory

examination findings were normal. Five days after
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Viral encephalitis caused by varicella zoster virus (VZV)
mainly occurs in immunocompromised individuals and
patients with VZV infection in the brain or nerves of the
cervical or upper thoracic spinal cord. However, viral
encephalitis caused by VZV affecting distant body parts,
such as herpes zoster of the waist and abdomen, is rare.
How herpes zoster virus reaches the central nervous
system (CNS) is unclear. We herein present an atypical
case of waist and abdomen herpes zoster infection that
progressed to the CNS in a 48-year-old healthy,
immunocompetent patient without brain magnetic reso-
nance imaging (MRI) abnormalities, and may enrich the
knowledge of viral encephalitis caused by herpes zoster.
Case report
A 48-year-old man was admitted to the Department of
Dermatology, People’s Hospital of Xinjiang Uygur Auton-
omous Region, with a 2-day history of fever, impaired
recognition and attention, reduced spontaneous speech,
inability to answer questions correctly, and abnormal
behavior (eg, brushing teeth with the end of toothbrush
handle and impaired handwriting). Two weeks before
presentation, the patient had developed clusters of small
erythematous vesicular lesions with acupuncture-like pain
on the right side of the waist and abdomen. He had no
fever or neurological symptoms at that time and his mental
∗ Corresponding authors: Dr. Yan-Yan Feng and Dr. Xiao-Jing Kang, Department
of Dermatology, People’s Hospital of Xinjiang Uygur Autonomous Region, Uygur,
Xinjiang 830001, China. E-mail: fyymed@163.com (Feng YY) and
Drkangxj666@163.com (Kang XJ).
Conflicts of interest: The authors reported no conflicts of interest.
Copyright © 2019 Hospital for Skin Diseases (Institute of Dermatology), Chinese
Academy of Medical Sciences, and Chinese Medical Association, published by
Wolters Kluwer, Inc.
This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-
ND), where it is permissible to download and share the work provided it is
properly cited. The work cannot be changed in any way or used commercially
without permission from the journal.
International Journal of Dermatology and Venereology (2019) 2:3
Received: 15 August 2018, Revised: 11 November 2018, Accepted: 12 January
2019
doi: 10.1097/JD9.0000000000000032
symptom onset, he was diagnosed with herpes zoster and
treated for the first 48 hours with oral acyclovir (800 mg
three times daily) followed by ganciclovir (intravenous
5 mg/kg twice daily), mecobalamin (vitamin B12, 0.5 mg
three times daily), dexketoprofen trometamol (12.5 mg
three times daily), and prednisone acetate tablets (15 mg
once daily) for 5 days. The blisters gradually became dry and
scarred. However, he suddenly developed lethargy,
impaired recognition, reduced spontaneous speech, inabili-
ty to answer questions correctly, and abnormal behavior
(eg, brushing teeth with the end of toothbrush handle and
impaired handwriting). The patient had no relevant
medical history.
Upon presentation, physical examination revealed a body
temperature of 38.5°C, blood pressure of 107/65 mmHg,
pulse of 80 beats/minute, and respiratory rate of 20 breaths/
minute. The next day, his treatment was changed to
acyclovir (intravenous 10 mg/kg three times daily), oxir-
acetam (intravenous 4 g once daily), and compound musk
injection (intravenous 20 ml once daily) for 2 days. He was
then admitted to our department, and neurological
examination showed that his nervous system abnormalities
were somewhat relieved (his cognitive function and ability
to answer simple questions correctly had recovered).
However, he still exhibited recall impairment and fatigue.
Clinical examination revealed several positive pathological
signs, which was consistent with the CNS lesions. Signs of
meningeal irritation were absent. Deep tendon reflexes,
strength, and sensation were normal. Routine blood
analyses showed a white blood cell count of 6.31  109/L,
red blood cell count of 4.6  1012/L, platelet count of 290 
109/L, neutrophil count of 2.87  109/L, lymphocyte count
of 2.99  109/L, monocyte count of 0.34  109/L, eosinophil
count of 0.06  109/L, and basophil count of 0.05  109/L.
The erythrocyte sedimentation rate was 16 mm/hour. Head
computed tomography and brain MRI and magnetic
resonance angiography were negative. Cerebrospinal fluid
(CSF) analysis showed a cell count of 9  106/L with an
increased proportion of monocytes, a positive Pandy test
result, total protein level of 0.6 g/L, glucose level of
2.72 mmol/L, lactic dehydrogenase level of 16.75 U/L, and
adenosine deaminase level of < 2U/L.

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Chen et al., Int J Dermatol Venereol (2019) 2:3
He was diagnosed with VZV encephalitis and treated with
acyclovir (intravenous 250 mg three times a day), oxiracetam
(intravenous 4 g once daily), and compound musk injection
(intravenous 20 ml once daily) for 5 days. His nervous system
symptoms were resolved, and at discharge he had achieved
near full recovery of his cognitive function and communicat-
ed without difficulty. His body temperature decreased to
36.8°C. At the 6-month follow-up, he had developed no CNS
recurrence or sequelae.
Discussion
Viral encephalitis refers to inflammation of the brain
parenchyma caused by viral infections and often
manifests as fever, headache, and disturbances in mental
function (eg, confusion, delirium, behavior changes,
dysphasia/aphasia, temporal lobe seizures, and focal
neurological signs proceeding to coma). These symptoms
distinguish viral encephalitis from meningitis, which is
characterized by the absence of nervous parenchymal
tissue involvement and which manifests as fever,
headache, and accompanying signs of meningeal irrita-
tion (photophobia, neck stiffness, and Kernig sign). Viral
encephalitis has a poor prognosis, high mortality rate, and
often severe sequelae.1
Viral encephalitis caused by VZV mainly occurs in
immunocompromised individuals, such as patients with
AIDS, patients who have undergone organ transplanta-
tion, patients of advanced age, and patients undergoing
immunomodulatory therapy. It also mostly occurs in
patients with VZV infection in the brain or nerves of the
cervical or upper thoracic spinal cord.2 Viral encephalitis
caused by VZV affecting distant body parts, such as herpes
zoster of the waist and abdomen, is rare.
The patient in the present case was diagnosed with VZV
encephalitis based on the following five factors: fever and
behavioral abnormalities as the main clinical manifesta-
tions, CSF analysis abnormalities (positive Pandy test
result, elevated protein, and decreased glucose), a history
of herpes zoster before neurological symptom onset,
improvement of symptoms following antiviral treatment,
and exclusion of alternative causes of the fever and
abnormal behavior.
Most patients with encephalitis have nervous system
symptoms and abnormalities on brain MRI or magnetic
resonance angiography. Some patients may have normal
MRI findings, although such cases are rarely reported.
Ricigliano et al.2 reported a 56-year-old immunocompe-
tent man developed brainstem encephalitis as a complica-
tion of Ramsay Hunt syndrome with normal MRI
findings, physical examination findings, chemistry param-
eters, and cell counts in the CSF. Finally, his diagnosis of
herpes zoster virus encephalitis was made and confirmed
by CSF VZV polymerase chain reaction.
The present case was a healthy, immunocompetent man,
who developed neurological symptoms 5 days after being
diagnosed as herpes zoster on the right side of the waist
and abdomen. MRI, routine blood analyses, autoimmune
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screening, and HIV and Treponema pallidum serology
yielded negative results. However, Pandy test was positive,
and CSF analysis showed elevated protein and decreased
glucose. After treatment with antiviral therapy, his
nervous system symptoms were somewhat relieved.
Finally, the diagnosis of herpes zoster viral encephalitis
was made. Unfortunately, detection of VZV DNA in the
CSF by reverse transcription polymerase chain reaction
was not performed due to conditional restrictions.
However, the patient had a favorable outcome in contrast
to previously reported cases, most of which had a poor
prognosis, high mortality, and often severe sequelae.
Administration of glucocorticoids to reduce inflammation,
adequate antiviral therapy, and nutritional neurotherapy
in the early stage of the disease may lead to successful
management of the condition.
How herpes zoster virus reaches the CNS is unclear. The
virus is thought to be directly transmitted from the anterior
and posterior roots of the spinal cord to the CNS or travel
to the CNS via immune-mediated demyelination and
vasculitis. Several paraclinical tools are used for early and
accurate diagnosis and management of immune-mediated
demyelinating disease. For example, MRI is the gold
standard technique to determine the spatiotemporal
pattern of demyelination, the diagnosis of viral encephali-
tis is based on the presence of focal lesions in the white
matter of the CNS, long T1 and T2 signal changes, and
hyperintense FLAIR images with a blurred lesion edge.
Cranial enhanced MRI suggests that multiple white matter
demyelinating lesions are present with no significant lesion
enhancement.3 Vasculitis/vasculopathy from VZV infec-
tion mainly causes cerebral and spinal infarction and
rarely hemorrhage.4 The use of corticosteroids and
immunosuppressive agents in patients with immunologi-
cally mediated vasculitis and demyelinating lesions has a
positive effect on the prognosis, whereas antiviral therapy
is not effective.
In our case, the patient developed neurological
symptoms and continued antiviral treatment, and we
added neuroprotective treatment (oxiracetam and com-
pound musk injection). The neurological symptoms
gradually eased on the third day. Additionally, no
obvious abnormality was present on head MRI. There-
fore, we presume that the herpes zoster virus in this case
was directly transported into the brain by retrograde
axoplasmic flow. This is a viral immune evasion
mechanism. Once inside the axon, the virus is invulnera-
ble to immune control. Further clinical studies are needed
to elucidate the access of herpes zoster virus to the CNS
and its pathogenesis. For patients developing a sudden
consciousness or behavioral disorder, we should carefully
inquire about their medical history, closely observe the
evolution of their condition, carefully perform a
neurological examination, and select reasonable auxiliary
examinations to avoid delayed treatment. Antiviral
treatment should be started as soon as viral encephalitis
is clinically suspected. Oral treatment (acyclovir or its
prodrug valacyclovir, which has better oral absorption)
Chen et al., Int J Dermatol Venereol (2019) 2:3
should be given in benign cases and IV acyclovir should
be given in severe cases such as those involving ocular
and CNS complications, especially in immunosuppressed
individuals. High-dose acyclovir should be used
(10 mg/kg IV every 8 hours for 21 days). Strict attention
must be given to the patient’s fluid balance because
dehydration increases the likelihood of acyclovir-induced
renal toxicity. Relapse occurs in up to 5% of patients and
requires continuation of treatment for an additional
7 days.5-6
In conclusion, for patients developing a sudden
consciousness or behavioral disorder, we should carefully
inquire about their medical history, closely observe the
evolution of their condition, carefully perform a neuro-
logical examination, and select reasonable auxiliary
examinations to avoid delayed treatment. Antiviral
treatment should be started as soon as viral encephalitis
is clinically suspected. Oral acyclovir or its prodrug
valacyclovir, which has better oral absorption, should be
given in benign cases, and intravenous acyclovir should be
given in severe cases such as those involving ocular and
CNS complications, especially in immunosuppressed
individuals.
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International Journal of Dermatology and Venereology
Acknowledgements
This study was supported by the National Natural Science Foundation
of China (No. 81660514) and the Xinjiang Uygur Autonomous
Region Natural Science Foundation (No. 2016D01C102).
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