Indian Journal of Ophthalmology

: 1965  |  Volume : 13  |  Issue : 2  |  Page : 73--74

Meningo-encephalitis and herpes zoster-varicella

SDD Kerawala 
 E. N. T. Dept. Sir Jamshedji Jeejeebhoy Hospital, Bombay, India

Correspondence Address:
SDD Kerawala
E. N. T. Dept. Sir Jamshedji Jeejeebhoy Hospital, Bombay

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Kerawala S. Meningo-encephalitis and herpes zoster-varicella.Indian J Ophthalmol 1965;13:73-74

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Kerawala S. Meningo-encephalitis and herpes zoster-varicella. Indian J Ophthalmol [serial online] 1965 [cited 2020 Oct 25 ];13:73-74
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Full Text

Since Von Bokay of Budapest sug­gested the probable relation of Herpes Zoster and a Varicella-like generalised skin eruption over half a century ago, there have been innumerable reports in the literature dis­cussing the various implications.

It was considered worthwhile to submit this case report particularly because of the rare finding of clinical­ly evident meningo-encephalitis with herpes zoster which is rare - Brian (1931, 1962).

Only 17 cases have been reported in the literature in the English language [Martin and others (1962)]. Clinical findings in our patient appear to fit into a set pattern as have been reported in the other 17 cases.

 Case Report

G. D. aged 68 had developed a culopapular eruption interspersed by maculopapular eruption interspersed by vesicles on the right auricle and en­ternal canal of the ear and in the distri­bution of the ophthalmic division of the right trigeminal nerve for ten days, when his doctor first noticed a genera­lised varicella-like eruption. There was no history of contact with Herpes Zoster or chickenpox. He showed signs of listlessness and apathy. There was a gradually deepening drowsiness and a rise of temperature for the next 8 hours. He had three generalised con­vulsion in rapid succession. On hospi­talization he was found deeply coma­tosed with a stertorous respiration and neck rigidity. His temperature was 102°F.

His ankle and knee jerks were ab­sent as were his plantar and flexor reflexes. There was no facial palsy. He regained consciousness within the next 8 hours without any loss of motor power or any residual sensory disturb­ances. His CSF. showed increased pres­sure, and was slightly turbid with a white cell count of 1500.

Examination of C.S.F. showed :

Polymorph-onuclears 10%.

Lymphocytes 90%.

RBCs. 350.

Protein 800 mg %.

Globulins in excess.

Chlorides 640 mg %.

Sugar 95 mg %.

No organisms on microscopy.

No growth on culture.

He had no personality changes, nor difficulty in speaking. However he was left with a right ptosis and a total ophthalmoplegia. His hearing on dis­charge was clinically normal.


Meningo-Encelphalitis seems to oc­cur most often in middle aged and elderly patients and invariably the patient is a male. The time of occur­rence of encephalopathy is from 1 to 6 weeks after the onset of skin lesions.

CSF. changes are found in approxi­mately 50% of zoster cases reported in the literature. These changes may persist for several weeks but very few develop manifest clinical signs of en­cephalitis: such as, altered state of consciousness, personality changes, speech difficulties and paresis. [Brown, W. H. (1919), Denny Brown and others (1944)].

As in many conditions caused by neurotropic or allied viruses a Meningo-Encephalitis of a variable degree, perhaps subclinical in most cases, invariably occurs. It is possible that minimal cerebral symptoms do occur which may not be noticed. In fact Welbaum E. and others (1962)

discussed their series of the Herpes Zoster cases under the heading "Herpes Zoster Encephalitis". They noticed clinical evidence of Meningeal irritation, delirium and psychoses, cranial nerve involvement, lid ptosis and facial palsy, hemiparesis and paraesthesia. They had no patients with coma or convulsions.

The majority of patients who deve­lop clinical signs of encephalitis have Herpes Zoster involving the Ophthal­mic division of the Trigeminal Nerve as compared to the other Nerve dis­tributions of the Head and Neck. [Cope and Jones (1954) Krumshots and Lukon (1959)].

In the pathogenesis of the Encelpha­litis it has been suggested that the hippocampal area can be affected by local spread of viruses from the cor­neal lesions, Fields and Blather, (1958).

It is generally believed that the encephalitis is transient and carries no mortality but this does not appear to be so since a fatal outcome has been reported in four cases. Thalmer (1924), Schiff & Brain (1930).[12]


A case of Herpes Zoster Ophthalmi­cus et oticus in coma is described. Evidence of Meningoencephalitis is rare in a case of herpes zoster. When found in the region of the head and neck, the herpes zoster is invariably found in the distribution of the oph­thalmic division of the Trigeminal Nerve although the patient had in ad­dition vesicles on the auricle and in the external canal of the ear on the same side. Of the 17 cases with manifest meningoencephalitis reported, 4 prov­ed fatal contrary to the general belief.


T am indebted to Dr. A. G. Emslie under whose care this patient was treated, for his encouragement and advice in the prepara­tion of this case report.


1Appelbaum. E., Krepps, S. I., Sunshine, A. (1961). Amer. J. of Med. 32: 25-31.
2Brain, W. R. (1931), B. M. J. 1: 81.
3Brain, W. R. (1962), Disease of the Nervous System. London. p. 428.
4Cope, S., Jones, A. T. (1954), Lancet ii. 898.
5Denny Brown, D., Adams, R. D., Fitzerald, P. J. (1944). Arch. Neurol and Psychiat. 51: 216.
6Fields, W. S., and Blattner, R. J. (1958). Symposium on Convulsive Disorder. p. 313-6.
7Ludsky, M. D., Kiass, D. W., McKenzie, B. F., and OLDSTEIN, N. P. (1962), Ann. of Int. Med. 56: 779.
8Madonick, M. J., (1946) Ibid. 56: 4.34.
9Martin, D., Ludsky, M. D., Donald, W., Klass, B. F. (1962). Ann. of Int. Med. 56: 779-84.
10Schiff, C. L., Brain, W. R. (1930), Lancet 2: 70.
11Thalimer, W. (1924). Arch. Neurol. Psychiat. 12: 73.
12Von Bokay (1909). Wien. Klin. Wochnschr. 22: 1323.