690 - Oka-Strain Varicella-Zoster Virus Meningitis in a Healthy Adolescent.

Background: Routine vaccination with varicella-zoster (VZV) vaccine has resulted in significant declines in the incidence of VZV cases, hospitalizations, and deaths across pediatric age. This vaccine is safe and effective and adverse events are monitored closely.

Methods: We describe a case of vOka meningoencephalitis in a twelve-year-old vaccinated boy who presented with altered mental status and a vesicular facial rash. 

Results: A twelve-year-old healthy, fully-vaccinated boy presented to urgent care clnic with left-sided frontotemporal headache, left-sided eye pain, and photosensitivity. Over several days, a left-sided facial rash progressed to include papular and vesicular lesions over the cheek, as well as over the left side of the chin and at the midline of the lower lip. He was somnolent, sleeping 18- 20 hours a day. The child was evaluated by a pediatric neurologist who noted a left-sided ptosis and left lateral rectus palsy; he was admitted for further workup. Cerebrospinal fluid (CSF) analysis showed WBC of 33 cells/ml³ with 92% lymphocytes; glucose of 44mg/dL (serum glucose 84mg/dL), and protein of 50mg/dL (range: 15-45). Nasopharyngeal multiplex polymerase chain reaction (PCR) (BioFire Diagnostics, Salt Lake City, Utah) was positive for rhinovirus/enterovirus. Testing of facial vesicles for varicella-zoster virus (VZV) and herpes simplex virus (HSV) was negative by DFA and culture, and enteroviral throat and rectal PCRs were negative. However, CSF PCR for VZV was found to be positive. In light of this finding, the viral isolate was sent to Dr. Anne Gershon's research lab at Columbia University Medical Center for typing and was determined to be vOka. Quantitative and functional immune studies were performed, and were normal. The patient initially received 7 days of intravenous acyclovir, during which time his rash resolved and mental status returned to baseline. He completed a total of 14 days of acyclovir and has had no recurrences.

Conclusion: This case represents only the tenth case of Oka-strain meningitis in an immunocompetent child reported to date, and one of very few cases in immunocompetent adolescents. While rare, vOka meningitis is an entity of which primary care pediatricians and infectious diseases specialists should be aware, even in older children.