What is the treatment for Varicella-Zoster Virus (VZV) meningitis?

From the Guidelines

Treatment for varicella-zoster virus (VZV) meningitis primarily involves intravenous aciclovir at a dose of 10 mg/kg three times daily for up to 14 days, especially if it can be started within a few days of symptom onset, as recommended by the Association of British Neurologists and British Infection Association national guidelines 1. The primary goal of treatment is to reduce morbidity, mortality, and improve quality of life.

• Key considerations in treatment include:
  • Adjusting the dose of aciclovir for patients with impaired renal function
  • Using a course of steroids, such as 60-80 mg of prednisolone daily for 3-5 days, due to the inflammatory nature of the lesion
  • Considering a prolonged course of intravenous aciclovir for immunocompromised patients with VZV encephalitis
• It is essential to note that VZV is less sensitive to aciclovir than HSV, and therefore, a higher dose of 15 mg/kg three times daily may be suggested if renal function is normal 1.
• The use of intravenous immunoglobulin and other antiviral agents, such as pleconaril, may not be widely recommended for VZV meningitis due to limited evidence and availability 1.
• Close monitoring of renal function, liver enzymes, and neurological status is crucial throughout treatment to minimize potential complications and ensure the best possible outcome.
• The guidelines for children with VZV CNS disease also support the use of antiviral treatments, such as aciclovir, and corticosteroids, particularly in cases of VZV vasculopathy 1.

From the FDA Drug Label

Varicella-Zoster Infections in Immunocompromised Patients A multicenter trial of Acyclovir for Injection at a dose of 500 mg/m2 every 8 hours for 7 days was conducted in immunocompromised patients with zoster infections (shingles). Acyclovir for Injection is indicated for the treatment of varicella-zoster (shingles) infections in immunocompromised patients.

The treatment for Varicella-Zoster (VZV) meningitis is not directly addressed in the provided drug labels. However, based on the information provided for the treatment of Varicella-Zoster infections in immunocompromised patients, the recommended dose of Acyclovir for Injection is 500 mg/m2 every 8 hours for 7 days 2.

• Key points:
  • Dose: 500 mg/m2 every 8 hours for 7 days
  • Population: Immunocompromised patients
  • Indication: Varicella-Zoster (shingles) infections It is essential to note that the provided information does not directly address VZV meningitis, and therefore, the treatment should be approached with caution and under the guidance of a healthcare professional. 2

From the Research

Treatment for VZV Meningitis

• The treatment for VZV meningitis typically involves antiviral medication, with options including oral valacyclovir and intravenous acyclovir 3, 4, 5, 6, 7.
• A study published in 2018 reported a case of a patient with VZV-associated meningitis who was successfully treated with oral valacyclovir after receiving two days of IV acyclovir 3.
• Another study published in 2022 found that early intravenous antiviral treatment for VZV meningitis and meningoencephalitis is important for a good outcome, and that the outcome at discharge was worse in male patients and when longer than 1.5 days passed between onset of neurological symptoms and initiation of antiviral treatment 4.
• A 2024 study found that patients with VZV meningitis had a good outcome, with no evidence of any impact of the treatment strategy, and that further studies are needed to support the possibility of milder treatment in immunocompetent patients, avoiding the cost and side effects of IV acyclovir 5.
• A 2020 study found that antiviral therapy reduced neurological morbidity in patients with VZV CNS infection, and that there was no increase in mortality in these patients 6.
• A 2024 study found that intravenous acyclovir is widely prescribed when VZV DNA is isolated in CSF, regardless of the clinical presentation, with a high rate of acute kidney injury (AKI), and that further studies are needed to better define the value of intravenous acyclovir in isolated VZV meningitis 7.

Antiviral Treatment Options

• Oral valacyclovir: has been shown to be effective in treating VZV meningitis in some cases 3, 5.
• Intravenous acyclovir: is widely prescribed for VZV CNS infection, but may be associated with a high rate of AKI 4, 7.
• Duration of treatment: can vary from 10 to 21 days, depending on the clinical presentation and response to treatment 6.

Patient Outcomes

• Age, underlying immunosuppression, and cranial radiculitis may be predictive factors for longer IV therapy 5.
• Male patients and those with a longer delay between onset of neurological symptoms and initiation of antiviral treatment may have a worse outcome at discharge 4.
• Antiviral therapy can reduce neurological morbidity and improve outcomes in patients with VZV CNS infection 6.