Rare presentation of primary varicella zoster as fatal fulminant hepatitis in adult on low-dose,short-term steroid: Case report

Abstract

BackgroundVaricella zoster virus presents clinically as primary (chickenpox) or secondary (herpes zoster) infection. Cutaneous and extracutaneous dissemination may occur, usually in immunocompromised patients. VZV hepatitis that progresses to fulminant hepatic failure is very rare and fatal. To the best of our knowledge, 9 cases have been reported to date, of which 7 were in immunocompromised adults, and only one patient was on short duration steroid therapy.Presentation of caseWe present a 26-year old man who was admitted initially with acute abdomen as query persistent biliary colic. Later, he showed clinical and laboratory findings of VZV hepatitis that progressed rapidly despite maximal medical ICU support and he expired on day 3 of admission.ConclusionsAcute VZV infection may present as fulminant hepatitis. The presentation may initially be challenging for the diagnosis and should be considered if the patient has been in contact with a sick case. Low dose corticosteroid could carry a risk for fatal VZV fulminant hepatitis and should be used very cautiously especially with VZV patients’ contacts. Further causative relationships remain to be established.

Varicella Pneumonia in an Elderly Patient

“…Hepatic involvement in varicella showed symptoms of vague epigastric pain, nausea, vomiting, and a possible increase in liver volume [11] . An increase in liver function test panel is expected, a couple of studies reported AST raised higher than ALT along with the increase of INR and bilirubin [12,13] . Risk factors for complications in varicella are newborns, adults, immunocompromised, males, smokers, and pregnant women.…”

“…Some studies showed clinical improvement, but some mentioned at risk of superinfections [16,17,18,19] . Reports showed that use of steroids prior varicella infection might cause fulminant hepatitis [12,13] . Nevertheless, the use of steroids remains a clinical decision [19] .…”

Predictive role of blood eosinophils in adult varicella patients

“…Normally, we tend to focus more on immunocompromised people because severe varicella mostly occurs in children and immunodeficient people [12]. However, in recent years, it has been reported that adult varicella patients with normal immune function have serious complications, such as acute respiratory distress, liver failure and cerebral venous sinus thrombosis [13][14][15][16]. Moreover, as adults typically do not voluntarily vaccinate against varicella, varicella infections in adults are likely undervalued and understudied.…”

Primary Varicella or Herpes Zoster? An Educational Case Report From the Primary Care Clinic

“…Hepatitis is another complication that should be identified promptly in adults with primary varicella [ 25 ]. It is essential to consider that immunosuppressed patients have a higher risk of this complication, usually presenting poor clinical outcomes [ 25 ]. However, mild transaminase elevation has been described even in healthy individuals with varicella [ 9 ].…”

“…Particular attention should be given to patients with two-fold or three-fold the upper normal rank value. These patients have a higher risk of hepatitis-associated complications such as disseminated intravascular coagulation (DIC) or gastrointestinal bleeding [ 25 ]. Of note, cases of fulminant acute hepatic failure, although rare, have been reported.…”