What is the treatment for shingles (herpes zoster) affecting the cerebrospinal fluid (CSF)?

Treatment for Shingles (Herpes Zoster) Affecting the Cerebrospinal Fluid

For herpes zoster affecting the cerebrospinal fluid, intravenous acyclovir 10 mg/kg every 8 hours should be administered for 14-21 days. 1

Diagnosis and Clinical Presentation

• Herpes zoster affecting the CSF typically presents as meningitis with signs including headache, photophobia, fever, and meningismus 1
• CSF analysis usually shows lymphocytic pleocytosis, mildly elevated protein, and normal glucose 1
• CSF PCR for VZV should be obtained to confirm the diagnosis 1
• It's critical to distinguish between VZV meningitis and encephalitis, as encephalitis is a more severe condition with potential for high neurologic morbidity and mortality 1

Treatment Recommendations

Acute Treatment

• For confirmed VZV affecting the CSF:
  • Administer intravenous acyclovir 10 mg/kg every 8 hours for 14-21 days in adults with normal renal function 1
  • Higher doses (20 mg/kg every 8 hours) are recommended for neonates 1
  • Treatment should be initiated as soon as possible after symptom onset 1

Monitoring During Treatment

• Monitor CSF pressure, as elevated intracranial pressure may require intervention 1
• Consider repeat CSF analysis at the end of therapy to confirm clearance of the virus, especially if clinical response is suboptimal 1
• If CSF PCR remains positive after treatment course, antiviral therapy should be continued 1

Special Considerations

• For immunocompromised patients:

  • Consider longer treatment duration 2
  • Monitor closely for disseminated disease 3
  • More aggressive treatment may be required 2

• For patients with ocular involvement:

  • Ophthalmology consultation is recommended 4
  • Specific ocular treatments may be necessary in addition to systemic therapy 4

Management of Complications

Elevated Intracranial Pressure

• If CSF pressure is ≥25 cm of CSF and there are symptoms of increased intracranial pressure:
  • Perform CSF drainage via lumbar puncture 1
  • Reduce opening pressure by 50% if extremely high or to a normal pressure of ≤20 cm of CSF 1
  • For persistent pressure elevation, repeat lumbar puncture daily until pressure and symptoms stabilize 1
  • Consider temporary percutaneous lumbar drains or ventriculostomy for patients requiring repeated daily lumbar punctures 1

Recurrent Episodes

• For recurrent episodes of VZV meningitis:
  • Oral therapy may be sufficient for established recurrent episodes 1
  • Note that valacyclovir 500 mg twice daily has not been shown effective for prevention of recurrent HSV-2 meningitis and may not be effective for VZV meningitis either 1, 5

Post-Treatment Follow-up

• Follow patients clinically after completion of therapy 1
• Monitor for potential neurological sequelae 1, 3
• Assess for any signs of recurrence, which may require additional treatment 1

Adjunctive Therapies

• Corticosteroids may be considered in VZV vasculopathy to reduce inflammation 2
• For pain management:
  • Appropriate analgesics should be provided 1
  • For postherpetic neuralgia, consider tricyclic antidepressants, anticonvulsants, or topical treatments 4

Prevention of Recurrence

• Long-term suppressive therapy has not been well-studied for VZV affecting the CSF 5
• Vaccination against herpes zoster may be considered for prevention in eligible patients after recovery 6

Pitfalls and Caveats

• Failure to distinguish between meningitis and encephalitis can lead to inadequate treatment duration 1
• Delayed initiation of antiviral therapy is associated with worse outcomes 1
• Relapse can occur after completion of therapy, requiring vigilant follow-up 1
• Steroid use should be carefully considered and not used routinely without specific indications 1