Quantitative real-time PCR analysis [12] of the CSF revealed presence of VZV-DNA with a concentration of 50

Quantitative real-time PCR analysis [12] of the CSF revealed presence of VZV-DNA with a concentration of 50.000 copies/mL indicating high viral replication. valacyclovir (3000?mg/day orally for 5 days). Additionally, we measured the intrathecal synthesis [13] of VZV immunoglobulin G antibodies (Enzygnost Anti-VZV/IgG, Siemens Healthcare Diagnostics) and found a specific antibody index (AI) of 74.9 (normal value 1.5). The presence of a strong intrathecal IgG Bay 65-1942 R form production against VZV confirmed the VZV contamination in the CNS. Eleven days after intravenous therapy, the patient was discharged feeling well. Follow-up CSF examination was performed 23 days after the end of antiviral treatment. A slight pleocytosis with 19 cells/ em /em L was still found. Plasma cells were not found and lymphocytes and monocytes showed normal morphology. VZV-PCR was unfavorable but a persisting intrathecal IgG production to VZV (specific antibody index of 21.5) indicated a preceding VZV contamination. The patient felt well without any symptoms. He used judo again four occasions per week. 3. Conversation Here we present a young previously healthy man with a VZV meningitis without rash. This case is Bay 65-1942 R form usually extraordinary because the clinical presentation was unusual for a patient with meningitis and the initial CSF findings with very high pleocytosis and elevated total CSF protein initially misleadingly suggested a bacterial infection. Interestingly, further CSF examinations detected a VZV contamination. Our case underlines the importance of Bay 65-1942 R form specialised CSF diagnostics in acute neurological emergency situations. CSF examination is generally considered a key process in the diagnosis of CNS infections [14]. Using sensitive laboratory analyses (e.g., PCR and detection of intrathecal production of specific antibodies) recent epidemiological studies found a portion of 5C29% of VZV in Bay 65-1942 R form aseptic meningitis and encephalitis and it was suspected that VZV infections had been underestimated in earlier publications [9, 15C18]. Nevertheless in immunocompetent patients without rash and neurological deficits (as in our case) VZV meningitis seems to be rare and only few cases have been explained to date (see Table 1). Infections of the CNS are accompanied by an elevated cell count in the CSF. In large series including patients with aseptic meningitis and encephalitis CSF findings predominantly revealed lymphomonocytic pleocytosis of less than 500 cells/ em /em L, moderate to moderately elevated total protein, and normal lactate levels [16C18]. In patients with Bay 65-1942 R form VZV contamination median cell counts of 43/ em /em L, Prkd2 132/ em /em L, 286/ em /em L, and 293/ em /em L were found and the cell counts ranged from 15 to 840 cells/ em /em L [9, 16C18]. In our case, we found the highest pleocytosis (1720 cells/ em /em L) that has been explained for this group of patients. In addition, total protein and lactate concentration were elevated leading to a misleading diagnosis of bacterial meningitis. In conclusion, even young and previously healthy patients without clinical features of dermal irritation such as rash might present with VZV meningitis. We spotlight the importance of considering VZV as a possible cause for meningitis even in previously healthy young patients and the recommended diagnostic lumbar puncture. Detailed CSF diagnostic procedures including PCR and detection of intrathecal synthesis of antiviral antibodies (especially for VZV and HSV) should be considered even though CSF cell count and total protein seem to show a bacterial infection. Discord of Interests The authors declare that there is no discord of interests regarding the publication of this paper..