Varicella zoster virus infection causing urinary retention in a child with HIV infection

Abstract

Varicella zoster virus (VZV) of the human herpes virus family causes childhood chickenpox, becomes latent in sensory ganglia and re-activates years later in immunocompromised and elderly persons to produce shingles (herpes zoster). The annual incidence of herpes zoster in children aged <10 years is reported to be 0.74 per 1 000 children per year.1 The association of VZV infection and neurogenic bladder dysfunction is rare and mostly seen in adults, with only one reported case in a child. 2Severe and debilitating zoster-associated dermatological, ophthalmological and neurological complications may occur in patients with HIV infection. 3 We describe the case of an HIV-positive child who presented with acute urinary retention secondary to VZV infection. Case descriptionAn 11-year-old boy was referred with urinary retention. He complained of difficulty passing urine, lower abdominal discomfort, and a painful rash over the perineum for 5 days. His mother had noticed that he had lower abdominal swelling.The patient was HIV-positive and receiving treatment accordingly (300 mg zidovudine twice daily, 250 mg didanosine daily and 200 mg/50 mg lopinavir/ritonavir twice daily). He was also receiving treatment for pulmonary tuberculosis, diagnosed 6 months prior (300 mg rifampicin and 150 mg isoniazid daily). The boy had no previous history of chickenpox.On examination, the patient was pyrexial (temperature 39°C) and appeared acutely ill. His bladder was distended, easily palpable and mildly tender. His penis, scrotum and perineum over dermatomes S2 -S4 on the left were involved with a vesicular and superficially erosive rash. Severe swelling of the prepuce caused the appearance of phimosis (Fig. 1). On digital rectal examination, his anal tone was normal.The bulbocarvernosus reflex was not tested due to severe tenderness in the perineal area. No abnormalities were found on neurological examination of his lower limbs.An 8F Foley catheter was inserted transurethrally and 1 500 ml of clear urine was drained. The boy was admitted to hospital and treated with 300 mg acyclovir 6-hourly (intravenous), 4 drops of oral tilidine 6-hourly and 1 000 mg paracetamol 8-hourly.An 11-year-old boy receiving antiretroviral therapy for HIV infection and antibacterial therapy for pulmonary tuberculosis presented with urinary retention due to varicella zoster virus infection involving the sacral nerves, confirmed on serological testing. The perineum over dermatomes S2 -S4 on the left was involved with a vesicular and superficially erosive rash. A transurethral catheter was inserted and the patient was treated with acyclovir (300 mg 6-hourly for 5 days). At follow-up 4 weeks later, the perineal skin lesions had healed, the catheter was removed and the patient was able to pass urine.