Fulminant varicella-zoster virus meningoencephalitis without rash: Aggressive perivascular necrotizing and leptomeningeal MRI findings

Varicella-zoster virus (VZV) can cause a wide spectrum of central nervous system (CNS) complications, including meningitis, encephalitis, and vasculopathy, occasionally in the absence of characteristic cutaneous manifestations. We report a case of fulminant VZV-associated CNS infection in an immunocompetent man in his 40s without rash, who presented with rapidly progressive impaired consciousness. Magnetic resonance imaging (MRI) revealed diffuse leptomeningitis, widespread intracranial vasculopathy, and extensive perivascular parenchymal lesions characterized by hemorrhage, necrotizing changes, and markedly restricted diffusion. Magnetic resonance angiography demonstrated irregular narrowing of the bilateral anterior and middle cerebral arteries, consistent with intracranial vasculopathy. Cerebrospinal fluid analysis using multiplex polymerase chain reaction detected VZV DNA, confirming the diagnosis. Despite antiviral therapy and supportive treatment, the clinical course was fatal. This case highlights that VZV CNS infection may produce aggressive perivascular destructive lesions beyond classic vasculopathy, even in patients without rash, and underscores the importance of comprehensive MRI evaluation in atypical fulminant presentations.