Visceral Varicella Zoster Virus (VZV) After Allogeneic Hematopoietic Stem Cell Transplant (HSCT) in Pediatric Patients With Chronic Graft-Versus-Host Disease (cGVHD)

Abstract

Reactivation of latent varicella zoster virus is one infectious complication associated with the extensive immunosuppression necessary for hematopoietic stem cell transplant. Most cases are limited to skin and mortality is low. Isolated visceral zoster is rare, presenting with ileus/abdominal pain, hepatitis, and/or hyponatremia. We present 2 cases of visceral varicella zoster virus in adolescents with chronic graft-versus-host disease after hematopoietic stem cell transplant. Both presented with elevated liver enzymes, severe abdominal pain, and hyponatremia but lacked cutaneous involvement. Both received high-dose acyclovir and showed improvement, but eventually expired from hepatic failure. The diagnosis of visceral zoster can be difficult especially without cutaneous manifestations. Vigilance is necessary in patients with chronic graft-versus-host disease, abdominal pain, and/or hepatitis and antiviral therapy should be initiated promptly.

Cutaneous Infections Caused by Herpesviridae: A Review

“…However, these methods are more expensive and availability may be limited. 8,20,23,25,26 Serology is sensitive, but not specific with immunoglobulin (Ig) G antibodies to a virus, only indicating a history of infection. Detection of IgM antibodies is mandatory to determine if the infection was recent.…”

“…8 Herpes zoster is heralded by a sensation of tingling and burning in a unilateral dermatomal distribution accompanied by fever, chills, headache, stomachache, and/or malaise. A maculopapular rash follows 48 to 72 hours later, with subsequent vesicles and ulcer formation similar to those of primary VZV.…”

Natural alteration of antibody titers in a patient with immunoglobulin A deficiency after chickenpox over a 10‐year period

“…Varicella is a highly contagious infection of varicella‐zoster virus (VZV), because it is an airborne transmitted virus 1 . This disease is mild in immunocompetent children, but life‐threatening in immunosuppressed children 2,3 . In Japan the varicella vaccine has not been used universally, so the same pattern of the epidemic occurs every year.…”

Fatal disseminated visceral varicella zoster virus infection in a renal transplant recipient

“…SOT recipients have a much greater risk of disseminated VZV, occurring in up to 40% of the patients and it is associated with high mortality rates of between 12.5%‐34% despite treatment . Visceral VZV infection is associated with a triad of hyponatremia, right upper–quadrant pain and transaminitis …”

“…[7][8][9] Visceral VZV infection is associated with a triad of hyponatremia, right upperquadrant pain and transaminitis. 10 Typically, post-transplant VZV infection occurs within the first year after transplantation, with a median onset post-transplant of 9 months. 5,6,11 However, disseminated VZV is often delayed, with median onset of 1.8-4.0 years following transplantation.…”