Chickenpox-associated fulminant hepatitis that led to liver transplantation in a 63-year-old woman

Abstract

A 63-year-old woman treated with prednisone for sinusitis developed fulminant liver failure due to a clinically unsuspected primary varicella zoster virus infection. The diagnosis of herpetic hepatitis was made from a liver biopsy, and varicella zoster virus viremia was detected by polymerase chain reaction. She was treated successfully with transplantation and perioperative administration of acyclovir. Liver Transpl 14:1309-1312, 2008. © 2008 AASLD. Received November 27, 2007 accepted February 25, 2008. Varicella or "chickenpox" is a very common and usually benign childhood disease due to a primary infection by the varicella zoster virus (VZV), which belongs to the alpha herpesvirus family. Up to 95% of the population is immunized during childhood, so varicella in adulthood is rare. Adulthood and immunodepression are predisposing factors for visceral involvement, with interstitial pneumonitis and meningoencephalitis being the most common visceral complications. Although varicella is frequently associated with mild hepatitis, fulminant liver failure is rare.1 Only a few cases have been reported; these mainly occurred during a primary infection in patients with impaired immunity. [1][2][3][4][5][6][7] We report here on the first case of an adult patient who underwent liver transplantation for fulminant liver failure related to a primary varicella infection. CASE REPORTOn July 23, 2005, a 63-year-old woman was admitted to a regional hospital for severe abdominal pain in the right lower quadrant with no fever. She had a history of asthma since the age of 20, requiring inhaled corticosteroids and bronchodilators. Ten days previously, she had suffered from sinusitis, which was treated with prednisone and pristinamycin for 7 days. At the time of admission, physical findings were not remarkable. Alanine aminotransferase and aspartate aminotransferase levels were 580 and 435 U/L respectively, with a normal prothrombin time and a white blood cell count (WBC) of 11 ϫ 10 3 /mm 3 . Abdominal ultrasound and chest X-ray findings were normal. Skin lesions were absent on the first day of admission. On day 2, a 2-cm-diameter cluster of clear vesicles on an erythematous base was noted on the right-hand surface of the abdomen, with no associated pruritus. This initial lesion was thought to be eczema. On day 3, this initial lesion progressed to pustules, and similar circular lesions were noted in the axillary cavities. In addition, several vesicles on an erythematous base appeared on the trunk. These lesions were considered to be impetigo, and local disinfection with eosin was performed, which impaired any further assessment of their course. On July 26, the patient's liver function worsened, and she was transferred to our intensive care unit for fulminant hepatitis. On admission, a clinical examination did Abbreviations: CMV, cytomegalovirus; HSV, herpes simplex virus; PCR, polymerase chain reaction; VZV, varicella zoster virus; WBC, white blood cell count. Address reprint requests to Anne-Marie Roque-Afonso,

Fulminant Hepatic Failure due to Varicella Zoster in a Heart Transplant Patient: Successful Liver Transplant

“…Although a moderate rise in liver enzyme levels is common in VZV infection, hepatitis is a rare life-threatening complication that, like others, mainly affects immunocompromised patients. 2,3,7 As well as by VZV, hepatitis can be caused by herpes simplex virus, Epstein-Barr virus, cytomegalovirus, and human herpesvirus 6, 1 as well as by adenoviruses, hemorrhagic fever viruses and, of course, the viruses of hepatitides A through E. Herpes viral origin must be considered in the case of immunocompromised patients with fever, to whom, pending the exclusion of such origin, parenteral acyclovir should be given in view of the risk of fastdeveloping FHF. In Spain, however, the most common cause of FHF is hepatitis B virus.…”

“…1 Fulminant hepatic failure (FHF) is an exceptional complication of VZV infection that generally involves primary infection of immunocompromised patients. [2][3][4] Here we report a case of successful liver transplantation in a heart transplant patient with FHF due to VZV infection.…”

Hepatitis viruses: Not always what it seems to be

“…Visceral involvement, including the liver, may occur in the immediate postoperative period or up to several months after transplantation. It is usually associated with rapid onset and fatal fulminant hepatitis [54][55][56] .…”

Simultaneous Occurrence of Varicella Zoster Virus-Induced Pancreatitis and Hepatitis in a Renal Transplant Recipient: A Case Report and Review of Literature

“…Cases have been reported in which immunocompetent patients have required liver transplantation after VZV-induced acute liver failure and have died because of multiorgan dysfunction after fulminant hepatic failure. [38][39][40] Gastrointestinal complications of varicella are common in immunocompromised patients. Gastrointestinal complications can manifest before the hallmark dermatologic manifestations of varicella, especially in immunocompromised individuals.…”