Varicella zoster meningitis complicating combined anti-tumor necrosis factor and corticosteroid therapy in Crohn’s disease

Abstract

Opportunistic viral infections are a well-recognized complication of anti-tumor necrosis factor (TNF) therapy for inflammatory bowel disease (IBD). Cases of severe or atypical varicella zoster virus infection, both primary and latent reactivation, have been described in association with immunosuppression of Crohn’s disease (CD) patients. However, central nervous system varicella zoster virus infections have been rarely described, and there are no previous reports of varicella zoster virus meningitis associated with anti-TNF therapy among the CD population. Here, we present the case of a 40-year-old male with severe ileocecal-CD who developed a reactivation of dermatomal herpes zoster after treatment with prednisone and adalimumab. The reactivation presented as debilitating varicella zoster virus meningitis, which was not completely resolved despite aggressive antiviral therapy with prolonged intravenous acyclovir and subsequent oral valacyclovir. This is the first reported case of opportunistic central nervous system varicella zoster infection complicating anti-TNF therapy in the CD population. This paper also reviews the literature on varicella zoster virus infections of immunosuppressed IBD patients and the importance of vaccination prior to initiation of anti-TNF therapy.

Keywords: Varicella zoster virus, Meningitis, Crohn’s disease, Adalimumab, Infliximab, corticosteroids, Anti-tumor necrosis factor

Core tip: Opportunistic viral infections can complicate anti-tumor necrosis factor (TNF) therapy for inflammatory bowel disease (IBD). Central nervous system varicella zoster virus (VZV) infections associated with the use of anti-TNF therapy have not been previously described in Crohn’s disease patients. We present the first reported case of VZV meningitis in a 40-year-old male with Crohn’s disease who developed reactivation dermatomal herpes zoster and VZV meningitis after treatment with adalimumab and prednisone. Despite aggressive antiviral therapy, he had significant morbidity, highlighting the risk of opportunistic viral infections in this population and the importance of vaccination before anti-TNF therapy.