From Shingles to Shutdown: A Rare Cascade of Catastrophic Complications

Introduction: Herpes zoster, though usually self-limited, can rarely cause severe complications including central nervous system involvement. Raoultella planticola, a rare gram-negative bacillus once considered environmental, has emerged as an opportunistic pathogen in critically ill patients. We present a unique case of a previously healthy middle-aged woman whose condition rapidly progressed from herpes zoster to brainstem infarction, cardiac arrest with post-anoxic brain injury, and ventilator-associated pneumonia caused by R. planticola.


Description: A 56-year-old woman with hypertension presented with left facial pain and was diagnosed with herpes zoster. She was treated with valacyclovir and gabapentin but returned days later with new right leg pain and was found to have a right posterior tibial vein DVT. Apixaban was started. Upon re-presentation with worsening symptoms, she was admitted and given empiric IV antibiotics. She soon developed right facial numbness and left-sided weakness. MRI revealed a lateral medullary infarct consistent with Wallenberg syndrome. She was not a candidate for thrombolysis due to anticoagulation and unclear stroke timing.
Her condition deteriorated, leading to pulseless electrical activity arrest requiring resuscitation and intubation. Post-arrest, she remained comatose. EEG showed burst suppression with intermittent facial myoclonus, consistent with post-anoxic myoclonic status. She was treated with levetiracetam, lacosamide, and sedation. During her ICU stay, she developed ventilator-associated pneumonia. Sputum cultures grew R. planticola, treated with targeted antibiotics. Despite aggressive care, there was no neurological recovery. Tracheostomy and PEG were performed after family discussions, and care was eventually withdrawn, resulting in death.


Discussion: This case illustrates the complex trajectory from a common viral illness to multi-system failure in an immunocompetent patient. VZV-related vasculopathy led to a brainstem stroke, with hypoxic-ischemic encephalopathy and post-anoxic myoclonus posing serious prognostic challenges. The identification of R. planticola in ventilator-associated pneumonia shows the need to consider emerging nosocomial pathogens in the ICU. Early recognition, multidisciplinary care, and vigilant infection control are critical.