Varicella Zoster Virus (VZV) has been rarely described to cause multiple cranial neuropathies and if disseminated is often associated with meningoencephalitis.  We present a case of polyneuritis cranialis in an immunocompromised patient with positive CSF VZV antibody but no other clinical evidence of meningoencephalitis.

A 67 year old man with a past medical history of HIV was admitted with a 6 day history of left ear pain with serous fluid leakage and a vesicular rash overlying the left ear and left tongue. He underwent ENT evaluation and was diagnosed with herpes zoster oticus and severe otitis externa. The patient was started on steroids, oral acyclovir, vancomycin and cefepime, but on hospital day 3 developed left sided 6^thand 7^thnerve palsy.  On exam the patient was afebrile with normal mentation and no nuchal rigidity. He had left sided lower motor neuron facial weakness and was unable to fully abduct his left eye.  MRI brain was unrevealing but lumbar puncture was positive for VZV antibody, 24 WBCs (90% lymphocytes) with normal protein and glucose. Intravenous antiviral therapy was started.  The patient initially progressed with development of dysphagia requiring nasogatric feeding tube, dysphonia with a paretic left vocal cord and vestibular dysfunction. Neck imaging to exclude other causes of dysphagia was unrevealing. With continued treatment the patient’s symptoms gradually improved and he was able to swallow. 

We present a case of an immunocompromised patient with CSF positive VZV antibody presenting with polyneuritis cranialis involving cranial nerves 6 through 10 without clinical evidence of meningoencephalitis. Testing the spinal fluid led to a change in treatment and stabilization of symptoms. Physicians should be aware of this unique presentation of VZV in order to provide appropriate treatment as early as possible.