Severe Varicella-Zoster Virus Encephalitis with Extreme Cerebrospinal Fluid Protein Elevation and Delayed Hydrocephalus in an Immunocompetent Patient in Shanghai

BackgroundVaricella-zoster virus (VZV) encephalitis typically presents with lymphocytic pleocytosis and mild-to-moderate elevation of cerebrospinal fluid (CSF) protein.Markedly elevated CSF protein concentrations and high viral loads are uncommon, particularly in immunocompetent individuals, and their clinical implications remain poorly defined. Case presentationWe reported a 67-year-old immunocompetent woman with VZV encephalitis who exhibited an extremely elevated CSF protein level (12.31 g/L) and a high CSF VZV viral load detected in CSF by next-generation sequencing.Neuroimaging revealed multifocal encephalitic lesions complicated by cerebral infarction and hemorrhage.The patient received standard antiviral and supportive management, with gradual clinical stabilization and marked improvement in CSF parameters.However, she developed delayed-onset hydrocephalus during the follow-up and underwent ventriculoperitoneal shunting, after which sustained neurological recovery was achieved. ConclusionsThis case broadens the spectrum of recognized CSF abnormalities in VZV encephalitis and underscores delayed hydrocephalus as a clinically important complication, even following apparent clinical and biochemical improvement.Prolonged surveillance may therefore be warranted in patients with severe VZV-related central nervous system infection.