Neonatal Varicella-Zoster Virus Meningitis Without Pleocytosis: Diagnostic Value of Polymerase Chain Reaction

Neonatal varicella is uncommon but may lead to severe complications, including central nervous system involvement. Cerebrospinal fluid findings may be misleading in neonates, and polymerase chain reaction-confirmed viral central nervous system infection may occur without pleocytosis, particularly when lumbar puncture is performed early in the course of illness. We report a 17-day-old term male neonate admitted with generalized vesicular rash and fever associated with irritability and poor feeding. Lumbar puncture performed on admission showed normal cerebrospinal fluid parameters without pleocytosis; however, a multiplex cerebrospinal fluid polymerase chain reaction panel was positive for varicella-zoster virus, and vesicular lesion polymerase chain reaction confirmed varicella-zoster virus infection. The neonate received intravenous acyclovir for 21 days with complete clinical recovery and normal follow-up. This case highlights that a normal cerebrospinal fluid cell count does not exclude neonatal viral central nervous system infection and supports early cerebrospinal fluid polymerase chain reaction testing to confirm varicella-zoster virus central nervous system involvement while rapidly excluding major differentials such as neonatal herpes simplex virus infection.