Herpes zoster ophthalmicus with atypical occipital lobe and splenial lesions: A case report

TL;DR

A 32-year-old man with a rash and headache was found to have an unusual brain lesion pattern caused by herpes zoster ophthalmicus, not a migraine.

Contribution

This case report highlights an atypical CNS involvement pattern in herpes zoster ophthalmicus in an immunocompetent adult.

Findings

The patient had simultaneous splenial and medial occipital lesions due to herpes zoster ophthalmicus.

MRI was more sensitive than CT in detecting subtle varicella-zoster-related encephalitic changes.

High-dose valacyclovir resolved the rash and headache within a week.

Abstract

A 32-year-old male with past medical history of migraine headaches (last episode 15 years prior) presented with persistent headache lasting 2 days and with associated nausea, photophobia and phonophobia concerning for migraine. Subsequent visits to outside facilities suggested a cortical/subcortical infarct of the left medial occipital lobe secondary to migraines. However, after continued symptoms and the subsequent development of a maculopapular rash along the right orbit and eyelid, suspicion grew that this was not a simple case of migraine induced infarct. Cerebral spinal fluid analysis showed markedly elevated VZV antibodies further raising suspicion. After a 1-week course of high-dose oral valacyclovir the rash and headache resolved. This case demonstrates an atypical pattern of CNS involvement in herpes zoster ophthalmicus, with simultaneous splenial and medial occipital lesions - an imaging pattern not commonly reported in immunocompetent adults. The findings also highlight the importance of a good clinical history and the superior sensitivity of MRI in detecting subtle varicella-zoster-related encephalitic changes when CT is nondiagnostic.

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