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Ishino Y, Fukasawa H, Kitamoto S, Nakagami D, Kaneko M, Yasuda H, Furuya R. A survival case of visceral disseminated varicella zoster virus infection in a patient with systemic lupus erythematosus. BMC Nephrol 2023; 24:164. [PMID: 37291486 PMCID: PMC10251651 DOI: 10.1186/s12882-023-03223-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/31/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Visceral disseminated varicella zoster virus (VZV) infection is a rare but life-threatening complication in immunosuppressed patients. Herein, we report a survival case of visceral disseminated VZV infection in a patient with systemic lupus erythematosus (SLE). CASE PRESENTATION A 37-year-old woman was diagnosed as SLE and initial induction therapy was started. Two months after starting the immunosuppressive therapy consisting of 40 mg of prednisolone (PSL) and 1500 mg of mycophenolate mofetil (MMF) daily, she suddenly developed strong abdominal pain, which was required opioid analgesics, followed by systemic skin blisters, which were diagnosed as varicella. Laboratory findings showed rapid exacerbation of severe liver failure, coagulation abnormalities and increased numbers of blood VZV deoxyribonucleic acid (DNA). Therefore, she was diagnosed as visceral disseminated VZV infection. Multidisciplinary treatment with acyclovir, immunoglobulin and antibiotics was started, the dose of PSL was reduced, and MMF was withdrawn. By their treatment, her symptoms were resolved and she finally discharged. CONCLUSIONS Our case highlights the importance of a clinical suspicion of visceral disseminated VZV infections, and the necessity of immediate administration of acyclovir and reduced doses of immunosuppressant to save patients with SLE.
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Affiliation(s)
- Yuri Ishino
- Renal Division, Department of Internal Medicine, Iwata City Hospital, 512-3 Ohkubo, Iwata, Shizuoka, 438-8550, Japan
| | - Hirotaka Fukasawa
- Renal Division, Department of Internal Medicine, Iwata City Hospital, 512-3 Ohkubo, Iwata, Shizuoka, 438-8550, Japan.
| | - Shuhei Kitamoto
- Renal Division, Department of Internal Medicine, Iwata City Hospital, 512-3 Ohkubo, Iwata, Shizuoka, 438-8550, Japan
| | - Daisuke Nakagami
- Renal Division, Department of Internal Medicine, Iwata City Hospital, 512-3 Ohkubo, Iwata, Shizuoka, 438-8550, Japan
| | - Mai Kaneko
- Renal Division, Department of Internal Medicine, Iwata City Hospital, 512-3 Ohkubo, Iwata, Shizuoka, 438-8550, Japan
| | - Hideo Yasuda
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Ryuichi Furuya
- Renal Division, Department of Internal Medicine, Iwata City Hospital, 512-3 Ohkubo, Iwata, Shizuoka, 438-8550, Japan
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Mizu D, Nishida H, Matsuoka Y, Ariyoshi K. Visceral disseminated varicella zoster infection: a rare cause of acute abdomen in a patient with well-controlled diabetes mellitus-a case report. BMC Infect Dis 2022; 22:215. [PMID: 35241009 PMCID: PMC8895882 DOI: 10.1186/s12879-022-07183-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 02/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Visceral disseminated varicella zoster virus (VZV) infections frequently affect immunocompromised patients. Diabetes mellitus has been associated with VZV infection, and most cases of disseminated infection involve patients with poorly controlled blood glucose levels. It initially presents as severe abdominal pain, which is evaluated as an acute abdomen, however, the cause is typically unidentified due to unremarkable computed tomography (CT) findings. We report a case of visceral disseminated VZV infection in a patient with well-controlled diabetes mellitus with fat stranding around the celiac and superior mesenteric artery on CT. CASE PRESENTATION A 61-year-old Japanese woman with well-controlled diabetes mellitus presented to the emergency department with severe abdominal pain that gradually worsened. She had stable vital signs and skin rashes, suggestive of varicella. Abdominal CT showed fat stranding around the celiac and superior mesenteric arteries. The patient tested positive for the VZV antigen and was diagnosed with a visceral disseminated VZV infection. Acyclovir was administered, and the patient was discharged on the 14th day. CONCLUSIONS Visceral disseminated VZV infection may affect patients with well-controlled diabetes mellitus and causes acute abdomen. Periarterial fat stranding on CT is associated with abdominal pain due to visceral disseminated VZV infection.
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Affiliation(s)
- Daisuke Mizu
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, 2-1-1, Minatojimaminami-machi, Chuo-ku, Kobe-shi, Hyogo, 650-0047, Japan.
| | - Haruka Nishida
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, 2-1-1, Minatojimaminami-machi, Chuo-ku, Kobe-shi, Hyogo, 650-0047, Japan
| | - Yoshinori Matsuoka
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, 2-1-1, Minatojimaminami-machi, Chuo-ku, Kobe-shi, Hyogo, 650-0047, Japan
| | - Koichi Ariyoshi
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, 2-1-1, Minatojimaminami-machi, Chuo-ku, Kobe-shi, Hyogo, 650-0047, Japan
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Furuto Y, Kawamura M, Namikawa A, Takahashi H, Shibuya Y. Successful management of visceral disseminated varicella zoster virus infection during treatment of membranous nephropathy: a case report. BMC Infect Dis 2019; 19:625. [PMID: 31307420 PMCID: PMC6632194 DOI: 10.1186/s12879-019-4193-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 06/14/2019] [Indexed: 01/01/2023] Open
Abstract
Background Visceral disseminated varicella zoster virus (VDVZV) infection is a rare disease with a high mortality rate (55%) in immunocompromised patients, but it is not yet widely recognized in the field of nephrology. We report a case of VDVZV contracted during immunosuppressive therapy for membranous nephropathy. Case presentation A 36-year-old woman was diagnosed with membranous nephropathy and was being treated with immunosuppressive therapy consisting of 60 mg/day prednisolone, 150 mg/day mizoribine, and 150 mg/day cyclosporine. Nephrosis eased; therefore, the prednisolone dosage was reduced. However, 50 days after starting immunosuppressive therapy, the patient suddenly developed strong and spontaneous abdominal pain, predominantly in the epigastric area, without muscular guarding or rebound tenderness. Blood data indicated neutrophil-dominant elevated white blood cell count, reduced platelet count, elevated transaminase and lactate dehydrogenase, slightly increased C-reactive protein, and enhanced coagulability. Abdominal computed tomography revealed a mildly increased enhancement around the root of the superior mesenteric artery with no perforation, intestinal obstruction, or thrombosis. The cause of the abdominal pain was unknown, so the patient was carefully monitored and antibiotic agents and opioid analgesics administered. The following day, blisters appeared on the patient’s skin, which were diagnosed as varicella. There was a marked increase in the blood concentration of VZV-DNA; therefore, the cause of the abdominal pain was diagnosed as VDVZV. Treatment with acyclovir and immunoglobulin was immediately started, and the immunosuppressive therapy dose reduced. The abdominal pain resolved rapidly, and the patient was discharged 1 week after symptom onset. Discussions and conclusions This patient was VZV-IgG positive, but developed VDVZV due to reinfection. Abdominal pain due to VDVZV precedes the skin rash, which makes it difficult to diagnose before the appearance of the rash, but measuring the VZV-DNA concentration in the blood may be effective. Saving the patient’s life requires urgent administration of sufficient doses of acyclovir and reduced immunosuppressive therapy.
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Affiliation(s)
- Yoshitaka Furuto
- Department of Hypertension and Nephrology, NTT Medical Centre Tokyo, 5-9-22, Higasi-Gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan.
| | - Mariko Kawamura
- Department of Hypertension and Nephrology, NTT Medical Centre Tokyo, 5-9-22, Higasi-Gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Akio Namikawa
- Department of Hypertension and Nephrology, NTT Medical Centre Tokyo, 5-9-22, Higasi-Gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Hiroko Takahashi
- Department of Hypertension and Nephrology, NTT Medical Centre Tokyo, 5-9-22, Higasi-Gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Yuko Shibuya
- Department of Hypertension and Nephrology, NTT Medical Centre Tokyo, 5-9-22, Higasi-Gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
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Herpes viruses in transplant recipients: HSV, VZV, human herpes viruses, and EBV. Hematol Oncol Clin North Am 2011; 25:171-91. [PMID: 21236397 DOI: 10.1016/j.hoc.2010.11.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The herpes viruses are responsible for a wide range of diseases in patients following transplant, resulting from direct viral effects and indirect effects, including tumor promotion. Effective treatments and prophylaxis exist for the neurotropic herpes viruses HSV-1, HSV-2, varicella zoster virus, and possibly HHV-6. Antivirals seem to be less effective at prevention of the tumor-promoting effects of Epstein-Barr virus and HHV-8. Reduction in immunosuppression is the cornerstone to treatment of many diseases associated with herpes virus infections.
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Shiley K, Blumberg E. Herpes Viruses in Transplant Recipients: HSV, VZV, Human Herpes Viruses, and EBV. Infect Dis Clin North Am 2010; 24:373-93. [DOI: 10.1016/j.idc.2010.01.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Chan SS. An unusual cause of abdominal pain: implications for infection control in the ED. Am J Emerg Med 2008; 26:1062-3. [DOI: 10.1016/j.ajem.2008.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2008] [Accepted: 07/22/2008] [Indexed: 12/28/2022] Open
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Boeckh M, Kim HW, Flowers MED, Meyers JD, Bowden RA. Long-term acyclovir for prevention of varicella zoster virus disease after allogeneic hematopoietic cell transplantation--a randomized double-blind placebo-controlled study. Blood 2006; 107:1800-5. [PMID: 16282339 PMCID: PMC1895699 DOI: 10.1182/blood-2005-09-3624] [Citation(s) in RCA: 164] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2005] [Accepted: 10/24/2005] [Indexed: 11/20/2022] Open
Abstract
Varicella-zoster virus (VZV) disease occurs in 30% of allogeneic hematopoietic cell transplant recipients who had a history of VZV infection. A safe and effective prevention strategy has not been established. In a double-blind controlled trial, 77 hematopoietic cell transplant recipients at risk for VZV reactivation were randomized to acyclovir 800 mg twice daily or placebo given from 1 to 2 months until 1 year after transplantation. VZV disease at 1 year was the primary end point; VZV disease after discontinuation of prophylaxis, VZV-specific T-cell immunity, herpes simplex virus (HSV) infection, cytomegalovirus (CMV) disease, survival, and safety were secondary end points. Acyclovir significantly reduced VZV infections at 1 year after transplantation (HR, 0.16; 95% CI, 0.035-0.74; P = .006). In the post-intervention observation period, this difference was not statistically significant (2 years: HR, 0.52; 95% CI, 0.21-1.3; 5 years: HR, 0.76; 95% CI, 0.36-1.6). There was no statistically significant difference in reconstitution of VZV-specific T-helper cell responses, HSV infections, CMV disease, chronic graft-versus-host disease, and overall survival between the groups. Acyclovir was well tolerated. Post-study VZV disease predominantly occurred in patients with continued need for systemic immunosuppression. In conclusion, acyclovir effectively and safely prevents VZV disease during the first year after hematopoietic cell transplantation. Periods of prophylaxis longer than 12 months may be beneficial for those hematopoietic cell transplant recipients on continued immune suppression.
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Affiliation(s)
- Michael Boeckh
- Fred Hutchinson Cancer Research Center, Program in Infectious Diseases, 1100 Fairview Ave N, Seattle, WA 98109, USA.
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Yang CP, Lee CH, Borel CO, Yeh CC, Lu CH, Wong CS, Wu CT. Postdural Puncture Headache with Abdominal Pain and Diarrhea. Anesth Analg 2005; 100:879-881. [PMID: 15728082 DOI: 10.1213/01.ane.0000143569.63214.04] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Dural puncture or a rent in the dura with prolonged cerebrospinal fluid leakage may cause noninfectious arachnoiditis and may be associated with urinary and fecal incontinence. Visceral dysfunction is common for patients with noninfectious arachnoiditis of the lumbosacral nerve roots after dural puncture. We report a case of postdural puncture headache associated with abdominal pain and diarrhea. An epidural blood patch was performed, and all symptoms resolved after 5 days. After exclusion of organic and psychological disorders, this treatment might be considered for patients who are experiencing abdominal pain and diarrhea after dural puncture.
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Affiliation(s)
- Chih-Ping Yang
- *Division of Anesthesiology, Armed Forces Taoyuan General Hospital; Departments of †Anesthesiology and ‡Orthopaedic Surgery, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China; and §Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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