Should herpes zoster meningitis patients be isolated?

Isolation Requirements for Herpes Zoster Meningitis

Patients with herpes zoster meningitis should be placed under airborne and contact precautions until all lesions are dry and crusted. 1

Isolation Protocol Based on Clinical Presentation

The isolation requirements for herpes zoster meningitis depend on the extent of the disease and the patient's immune status:

For All Patients with Herpes Zoster Meningitis:

• Airborne precautions: Negative air-flow room required
• Contact precautions: To prevent direct transmission from lesions
• Duration: Until all lesions are dry and crusted 1

Additional Considerations:

1. Immunocompromised patients: Maintain strict airborne and contact precautions even with localized herpes zoster until disseminated infection is ruled out 1
2. Disseminated zoster (lesions in >3 dermatomes): Requires strict airborne and contact isolation 2
3. If negative air-flow rooms are unavailable: Isolate patients in closed rooms and restrict contact with non-immune persons 1

Staff Management

• Only healthcare personnel with evidence of immunity to varicella should care for patients with herpes zoster meningitis 1
• Evidence of immunity includes:
  • Documented receipt of 2 doses of varicella vaccine
  • Laboratory evidence of immunity or laboratory confirmation of disease
  • Diagnosis or verification of a history of varicella or herpes zoster by a healthcare provider 1

Transmission Risk Factors

Herpes zoster meningitis presents a significant transmission risk because:

• VZV can be transmitted through airborne route from patients with herpes zoster 1
• Neurological involvement suggests potential for higher viral load and increased risk of transmission 3, 4
• Transmission can occur even without direct contact with the index case 1

High-Risk Contacts

Special attention should be given to protecting these vulnerable populations:

• Pregnant women without immunity to varicella
• Premature infants born to susceptible mothers
• Infants born at <28 weeks' gestation
• Immunocompromised individuals 1, 2

Post-Exposure Management

For exposed healthcare workers without immunity:

• Exclude from duty from the 8th day after first exposure through the 21st day after last exposure
• If varicella develops, exclude until all lesions are dry and crusted 1
• Consider post-exposure vaccination within 3-5 days of exposure 1

Common Pitfalls to Avoid

1. Inadequate isolation: Failing to implement both airborne and contact precautions can lead to nosocomial transmission
2. Premature discontinuation of isolation: Isolation should continue until all lesions are completely crusted, not just improving
3. Allowing non-immune staff to care for patients: This increases risk of transmission and potential furloughing of exposed staff
4. Delayed recognition: Herpes zoster meningitis may not present with typical dermatomal rash patterns, potentially delaying appropriate isolation 4

Proper isolation of patients with herpes zoster meningitis is essential to prevent nosocomial transmission, which can have serious consequences for vulnerable patients and lead to significant disruption in healthcare settings.