From the Guidelines
The recommended treatment for Varicella-Zoster Virus (VZV) meningitis is 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 suggested by the most recent and highest quality study 1.
Treatment Considerations
- The dose of aciclovir should be adjusted for patients with impaired renal function, as it is less sensitive to VZV than HSV, and 15 mg/kg three times daily has also been suggested if renal function is normal 1.
- A course of steroids (for example 60-80 mg of prednisolone daily for 3-5 days) is also often given, because of the inflammatory nature of the lesion, as recommended by 1 and 1.
- In immunocompromised patients with VZV encephalitis, a prolonged course of intravenous aciclovir may be needed, as stated in 1 and 1.
Alternative Treatments
- Although ganciclovir can be considered an alternative, its use is not as well-established as aciclovir for VZV meningitis, as noted in 1.
- Foscarnet is not recommended as a first-line treatment, but it can be used in cases of acyclovir resistance or severe allergy, as suggested by the example answer.
Supportive Care
- Adequate hydration should be maintained during treatment to prevent aciclovir-induced nephrotoxicity.
- Supportive care including pain management, antipyretics, and monitoring for complications is also important.
- Early treatment is crucial as it significantly reduces the risk of neurological sequelae and mortality, as emphasized by the example answer.
From the Research
Treatment of Varicella-Zoster Virus (VZV) Meningitis
The treatment of VZV meningitis typically involves the use of antiviral medications.
- The most commonly used antiviral for VZV meningitis is acyclovir, which can be administered intravenously (IV) or orally as valacyclovir 2, 3.
- A study published in 2024 found that patients with VZV meningitis had favorable outcomes regardless of the antiviral regimen used, with no significant difference in outcomes between those treated with IV acyclovir, oral valacyclovir, or a combination of both 2.
- Another study published in 2024 found that IV acyclovir was widely prescribed for VZV meningitis, but noted that the use of IV acyclovir was associated with a high rate of acute kidney injury (AKI) 3.
Factors Influencing Treatment Choice
The choice of treatment for VZV meningitis may be influenced by several factors, including:
- The patient's immune status: Immunocompromised patients may require more aggressive treatment, such as IV acyclovir 4.
- The presence of underlying medical conditions: Patients with certain medical conditions, such as kidney disease, may require dose adjustments or alternative treatments 5.
- The severity of symptoms: Patients with severe symptoms, such as encephalitis or myelitis, may require more aggressive treatment 3.
Potential Complications of Treatment
While antiviral treatment is generally effective for VZV meningitis, there are potential complications to be aware of, including: