Skin rash and headache

An 11-year-old girl presented with headache and skin rash on the left side of her chest that had begun 3 days earlier. She had been diagnosed with varicella when she was 2 years old and therefore had no history of receiving the VZV vaccine. She did not have any episode associated with primary immunodeficiency.

Before the onset of illness, she felt fatigued due to exhaustive preparation for a school gymnastics event over several weeks. Then, she visited the local clinic due to repeated afebrile vomiting and severe headache.

Upon her admission, physical examination revealed a body temperature of 37.2 °C, respiratory rate of 20 breaths/min, heart rate of 85 beats/min, and normal hemodynamic parameters with a blood pressure of 117/68 mmHg. She was noted to have a maculopapular rash evolving into vesicles with erythematous regions on the left side of her chest. Her consciousness was clear, and her deep tendon reflexes were normal; Kernig’s sign was negative, although she had neck stiffness.

A cerebrospinal fluid (CSF) examination revealed normal protein concentration (36 mg/dl), normal glucose level (47 mg/dl; blood glucose level, 92 mg/dl), and lymphocytic pleocytosis (429 lymphocytes/μl). The bacterial culture of CSF yielded no growth. Varicella-zoster virus (VZV) deoxyribonucleic acid (DNA) was detected in CSF by polymerase chain reaction (PCR) on day 5. Results of blood examination were within normal ranges, including white blood cells (7180/μl), leukocytes (5220/μl), lymphocytes (1507/μl), monocytes (287/μl), eosinophils (43/μl), and basophils (28/μl). VZV anti-complement immunofluorescence studies revealed 19 mg/dl of immunoglobulin G (IgG) and below 1 mg/dl of IgM. These indicate previous infection and acquisition of humoral immunity against VZV. Moreover, there was no increase in the inflammatory biomarker levels. She had normal levels of quantitative immunoglobulins and lymphocyte markers: IgG 1106 mg/dl (normal range, 870–1700 mg/dl), IgA 71 mg/dl (normal range, 110–410 mg/dl), IgM 132 mg/dl (normal range, 46–260 mg/dl), CD3 71.6% (normal range, 59–88%), CD4 32.1% (normal range, 29–65%), CD8 38.8% (normal range, 13–40%), CD4/CD8 ratio 0.83 (normal range, 0.9–3.2), CD19 12.8% (normal range, 4–26%), and CD56 15.5% (normal range, 2–26%).