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Visceral varicella-zoster virus (VZV) infection as an underestimated differential diagnosis of acute abdomen in a patient after allogeneic hematopoietic stem cell transplantation
Affiliations- Department of Pediatrics, Hematology and Oncology, Medical University of Gdańsk, Head: Prof. dr hab. n. med. Elżbieta Adamkiewicz-Drożyńska, Poland
- Department of Oncological Propedeutics, Medical University of Gdańsk, Head: Prof. dr hab. n. med. Janusz Kruszewski, Poland
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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.
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.
Keywords
Hematopoietic stem cell transplantation; Visceral varicella-zoster virus; Cholecystits; Acute abdomen; Graft-versus-host disease; Acyclovir prophylaxis
About this articleTitle
Visceral varicella-zoster virus (VZV) infection as an underestimated differential diagnosis of acute abdomen in a patient after allogeneic hematopoietic stem cell transplantation
Journal
Issue
Pages
372-377
Published online
2017-10-01
Page views
110
Article views/downloads
211
DOI
10.1016/j.achaem.2017.02.001
Bibliographic record
Acta Haematol Pol 2017;48(4):372-377.
Keywords
Hematopoietic stem cell transplantation
Visceral varicella-zoster virus
Cholecystits
Acute abdomen
Graft-versus-host disease
Acyclovir prophylaxis
Authors
Julia Radoń-Proskura
Ninela Irga-Jaworska
Anna Malinowska
Jan Maciej Zaucha