Varicella-Zoster Virus Infection and Osteomyelitis of the Skull.

Background: Varicella-zoster virus (VZV) is a common herpesvirus infection that can result in acute varicella/chickenpox, as well as delayed activation in herpes zoster/shingles. Ramsay-Hunt syndrome is a rare presentation of VZV reactivation, involving 1% of cases and resulting in lesion formation along the seventh cranial nerve distribution. We report the first case of a patient who presented with acute calvarial osteomyelitis after VZV reactivation and Propionibacterium acnes suprainfection.

Clinical Presentation: A 41-year-old man with a history of VZV presented with a 6-month history of chest pain, flulike symptoms, and left-sided headaches. Several concomitant external calvarial lesions were identified, and imaging was concerning for an infectious or neoplastic etiology. The patient underwent surgical debridement, and pathologic samples identified coinfection with P. acnes and VZV. Antibacterial and antiviral therapy resulted in a good outcome.

Conclusion: Osteomyelitis resulting as a complication of VZV infection is rare, particularly in the calvaria. This is the first reported case of Ramsay-Hunt syndrome-type VZV infection being complicated by osteomyelitis of the calvaria. Our case also demonstrates the diagnosis of VZV osteomyelitis through the use of current pathologic methods.