Visceral varicella-zoster virus (VZV) infection as an underestimated differential diagnosis of acute abdomen in a patient after allogeneic hematopoietic stem cell transplantation

Abstract

We report a case of 18-year-old male patient who 5.5 months after allogeneic hematopoietic stem cell transplant (HSCT) developed severe abdominal pain not responding to high dose of opioids. The pain was accompanied by gradually increasing activity of liver enzymes and bilirubin concentration. The patient had a history of acute GVHD and was on steroid taper. Importantly, he was also temporarily off standard acyclovir prophylaxis. Provisional diagnosis of acute cholecystitis was made, however, cholecystectomy did not improve patient's condition. Clinical picture of severe abdominal pain without clear surgical cause, resistant to high doses of opiates with increasing activity of liver enzymes was highly suspicious of visceral varicella zoster virus (VZV) reactivation. Immediate introduction of intravenous acyclovir led to full recovery and complete resolution of abdominal pain. We conclude that reactivation of latent VZV with absent or delayed occurrence of characteristic skin vesicles may still pose a diagnostic challenge resulting in delay of the proper diagnosis and start of life saving antiviral treatment. Severe intractable pain in HSCT recipients with increasing activity of liver enzymes should evoke high index of suspicion of the possible disseminated VZV and impose start of empirical treatment with high dose acyclovir.