# A Case of Multiple Intracranial Hemorrhages Due to Biopsy-Proven Varicella Zoster Virus Vasculopathy Without Rash

## TL;DR

An 80-year-old man with no rash had brain hemorrhages caused by varicella zoster virus vasculopathy, diagnosed through biopsy and treated with antiviral drugs and steroids.

## Contribution

This case highlights VZV vasculopathy as a rare cause of intracranial hemorrhage without rash, emphasizing the need for comprehensive diagnostic approaches.

## Key findings

- Brain biopsy confirmed VZV vasculitis despite undetectable VZV DNA in cerebrospinal fluid.
- Treatment with acyclovir and corticosteroids led to partial clinical improvement.
- CSF showed elevated protein and cell count, along with a high VZV IgG antibody index.

## Abstract

Varicella zoster virus (VZV) vasculopathy is a rare complication of VZV infection that can lead to severe neurological manifestations, including multiple intracranial hemorrhages. We report the case of an 80-year-old male patient with a history of Parkinson’s disease and hypertension who presented with altered consciousness and motor difficulties. Imaging studies revealed recurrent cortical-subcortical hemorrhages in the right frontal lobe. Laboratory tests showed elevated cerebrospinal fluid (CSF) protein, increased CSF cell count, and a significantly elevated VZV IgG antibody index, while CSF VZV DNA was undetectable. A brain biopsy confirmed the diagnosis, showing vasculitis with VZV DNA positivity via real-time polymerase chain reaction (PCR) and immunohistochemistry. The patient was treated with intravenous acyclovir and corticosteroids, which partially improved clinical outcomes. This case highlights the importance of considering VZV vasculopathy as a differential diagnosis in unexplained intracranial hemorrhages, even in the absence of typical skin lesions. Comprehensive diagnostic evaluation, including CSF antibody testing and brain biopsy, is essential for accurate diagnosis and management.