RESUMO
The herpes zoster infection occurs in the United States, particularly targeting those who are immunocompromised, and can present with many manifestations including encephalitis. Instances of varicella zoster virus (VZV) encephalitis in immunocompetent patients have been rarely reported, but such diagnoses are becoming more frequent as detection of VZV has improved with the adoption of molecular diagnostic panels such as the BioFire Film Array meningitis panel (Salt Lake City, USA). Here, we present an interesting case of acute meningoencephalitis in an immunocompetent adult female without dermatomal neuralgia or cutaneous lesions attributable to VZV. Given many inconsistencies between the patient's presentation and the positive polymerase chain reaction (PCR) result for VZV, we suspected our patient was infected with an undetected organism while possibly simultaneously shedding previously acquired VZV. As molecular diagnostic panels are increasingly used and have greatly improved detection of rarer etiologies of disease, we encourage clinicians to interpret results with caution.
RESUMO
Cavernous sinus thrombosis (CST) is a rare life-threatening condition where a blood clot develops within the cavernous sinus secondary to various etiologies, ranging from infection to aseptic causes (e.g., trauma or surgery). The dural sinuses and the cerebral veins have no valves, which allow retrograde blood flow according to pressure gradients. As a result, cavernous sinuses are vulnerable to septic thrombosis from infection at various sites including sphenoid and ethmoid sinuses. Less commonly, infections of the face, ears, nose, tonsils, soft palate, and teeth may lead to CST if treatment is delayed. Clinical findings of CST extending to the opposite cavernous sinus typically requires 24-48 hours after the initial presentation of orbital signs. However, we present a patient with facial and orbital cellulitis that was immediately treated with high-dose IV antibiotics within one hour of presentation and IV heparin six hours after admission and CST diagnosis. However, the patient developed a rapid progression of bilateral CST within six hours, unresponsive to treatment. Although facial cellulitis may lead to septic CST if untreated, the rapid progression of bilateral CST in the setting of acute hypoxic respiratory failure, renal failure, and coagulation abnormalities suggests a possible underlying infection and complications similar to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.
