Varicella-Zoster Virus (VZV) Infection as a Possible Cause of Ogilvie's Syndrome in an Immunocompromised Host

Abstract

We describe an immunodeficient adult with Ogilvie's syndrome preceding a disseminated papulovesicular skin rash in whom varicella-zoster virus infection was demonstrated by PCR assay in cutaneous and colonic biopsy specimens. In view of the significant morbidity and mortality that this condition carries, early and accurate molecular diagnosis and timely treatment are strongly recommended. CASE REPORTA 62-year-old white man was admitted in June 2013 because of a 6-day history of severe and worsening abdominal pain and vomiting. He had been diagnosed with stage IIIA, diffuse large B-cell lymphoma in 2004, when complete remission was achieved following immunochemotherapy (rituximab, cyclophosphamide, adriamycin, vincristine, and prednisone [R-CHOP]). In 2008, he received immunochemotherapy as a salvage treatment for relapse (rituximab, etoposide, cytarabine, cisplatinum, and methylprednisolone [R-ESHAP]) and an autologous hematopoietic stem-cell transplant, reaching complete remission once more. Afterwards, the patient was given consolidation chemotherapy until October 2012, bendamustine being the last agent prescribed. A positron emission tomography scan performed in May 2013 displayed normal findings. His medical history also included diabetes mellitus and an episode of herpes zoster on the right T 12 dermatome 15 months before admission. He denied opiate, phenothiazines, or calcium channel blocker administration, chronic constipation, or recent trauma or surgical intervention. He was not on immunosuppressive therapy.On admission, the patient was afebrile and hemodynamically stable. Physical examination revealed profound abdominal distention and decreased bowel sounds but no signs of peritoneal irritation. Blood tests were significant for leucopenia and lymphopenia (2.3 ϫ 10 9 /liter leukocytes, 71.4% neutrophils, 16.8% lymphocytes), mild anemia (hemoglobin, 119 g/liter), and an accelerated erythrocyte sedimentation rate (45 mm/h). His total Tcell count and CD4 ϩ T-cell count were 0.317 ϫ 10 9 /liter and 0.012 ϫ 10 9 /liter, respectively. An abdominal computed tomography (CT) scan showed marked colonic dilatation and a possible narrowing at the rectosigmoid junction; pneumoperitoneum or ascites were absent (Fig. 1). An ensuing colonoscopy ruled out strictures and was remarkable only for a solitary sigmoidal ulcerative lesion (Fig. 2) which was subjected to a biopsy procedure (Fig. 3). Simultaneous control biopsy specimens taken from an endoscopically normal right colon revealed normal findings. An upper gastrointestinal endoscopy displayed no abnormalities. At that time, emergency, internal medicine, and surgery physicians were unable to ascertain the origin of the large bowel distension.Moreover, the patient's complaints required intravenous tramadol, paracetamol, and metamizole treatment. On the third hospital day, he developed a cutaneous, diffuse exanthematous papulovesicular rash most consistent with disseminated herpes zoster (Fig. 4)-one of these lesions was subjected to a biopsy procedure on the same day...

Molecular Aspects of Varicella-Zoster Virus Latency

“…Additionally, VZV DNA and a restricted number of viral transcripts have been detected in intestinal biopsies of naturally infected and vaccinated individuals [ 69 , 76 , 77 , 78 ]. Although in situ detection of VZV DNA or RNA in human enteric neurons is lacking, clinical evidence suggests that VZV reactivation from the enteric nervous system (ENS) could be associated with gastrointestinal dysfunction [ 79 , 80 , 81 ], possibly resulting from reactivation-induced damage to ENS neurons or virus replication in the gut wall.…”

Simian Varicella Virus Infects Enteric Neurons and α4β7 Integrin-Expressing Gut-Tropic T-Cells in Nonhuman Primates

“…VZV infection of the ENS has been studied in ante- and postmortem human intestine biopsies, and more thoroughly in the guinea pig model of VZV infection [ 3 , 4 , 5 , 6 , 7 ]. VZV inoculation of guinea pigs leads to infection and viral persistence in ENS neurons [ 4 ], and virus reactivation can be induced in vitro using VZV-infected isolated guinea pig ENS neurons [ 3 , 4 ].…”

Reactivation of Simian Varicella Virus in Rhesus Macaques after CD4 T Cell Depletion

“…months after zoster in arteries of patients with vasculopathy (7). Significant inflammation is also seen in colon biopsy specimens from zoster patients with pseudo-obstruction (8). Zoster-associated lymphadenitis has also been reported (9).…”