Varicella zoster virus meningitis with a dermatomal rash in immunocompetent hosts: a systematic review and novel case report.

Varicella zoster virus (VZV) reactivation with central nervous system (CNS) involvement is an uncommon but important cause of lymphocytic meningitis in both immunocompromised and immunocompetent individuals. While cranial presentations, especially V1 involvement, are well documented, spinal-dermatomal VZV meningitis is rarely reported. We conducted a systematic review of PubMed, Scopus, and Embase using PRISMA guidelines to identify all cases of laboratory-confirmed VZV meningitis or encephalitis with a dermatomal rash in immunocompetent adults affecting spinal levels C1 and below. Data extracted included demographics, dermatome distribution, CSF findings, treatment, and outcomes. We also report a novel case from our institution involving isolated C4-C5 involvement. Seventeen total cases met inclusion, including our 44-year-old male patient who presented with fever, severe headache, and a right-sided vesicular rash in the C4-C5 dermatomes. He was initially misdiagnosed with a tick-borne illness. Mean CSF values across all cases were WBC count 382/µL (SD ± 270), protein 177 mg/dL (SD ± 106), and glucose 52.7 mg/dL (SD ± 15.8). IV acyclovir was used in 15 of 17 cases, with oral acyclovir (41%) or valacyclovir (29%) as the most common step-down therapies. Mean treatment duration was 14 days, and average length of hospital stay was 6.4 days. All patients survived and made a full recovery. Spinal-dermatomal VZV meningitis can occur in immunocompetent adults, including cases with cervical involvement. Early recognition of the rash pattern and timely PCR testing are essential for accurate diagnosis and prompt antiviral therapy, which is associated with favorable outcomes.