Skin, pneumonia, hepatitis, and more a rare presentation of varicella zooster

SESSION TITLE: Critical Care Case Report Posters 8 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Varicella-zoster virus (VZV) belongs to the herpesviruses group and known to cause two clinically distinct forms of disease: varicella (chickenpox) and herpes zoster (shingles). Hepatic involvement with varicella is uncommon and generally affects immunosuppressed and transplant recipients and AIDS patients but the outcome is frequently fatal. CASE PRESENTATION: 67 Years Female with PMH of Hypertension and depression, who presented to the ED with diffuse abdominal pain and nausea for 3 days. She is a social drinker and was afebrile and had normal vitals. Examination showed the Shingles rash involving right lower thoracic region T5-T7 dermatomal distribution. Chest X ray showed diffuse left upper and midlung infiltrates, bilateral lower lobe infiltrates most marked on the left. For possible VZV pneumonia with suspected secondary bacterial community acquired pneumonia she was treated with broad spectrum antibiotics including ceftriaxone and azithromycin.Admission Labs showed- AST : >3600, ALT 1902, ALP 280.8, Bilirubin 0.7, Albumin 2.4, INR1.43 , Urine and serum toxicology were negative with normal serum alcohol level. Ammonia level was 69.8 with normal Lipase, troponin and renal functions. She reported no Hx of herbal meds, or OTC use of Acetaminophen, Aspirin, and illicit drug use. Hepatitis panel, HIV, CMV, EBW serologies and collagen vascular disease/autoimmune workups including ANA panel, Atypical pneumonia workups were all negative.Imaging with CT abdomen pelvis with contrast showed poorly visualized contracted gallbladder with several gallstones. USG abdomen showed gallstones, with normal CBD. Patient was treated with lactulose and rifaximin and N acetyl cysteine. In the absence of other evident causes of raised liver function tests, a diagnosis of VZV induced hepatitis with Pneumonia indicating VZV as etiology was made. She was treated with oral valacyclovir, and liver function started to downtrend and reached to baseline in ~10 days of the hospital stay. DISCUSSION: Varicella infection can cause complications including skin and soft tissue infections including cellulitis, myositis (42 %), dehydration (11 %), encephalitis and, Reye syndrome (9 %). Uncommon complication of the Varicella such as pneumonia has incidence ~5% in immunocompetent patients with mortality upto 30%. Hepatic involvement with varicella is uncommon and generally affects immunosuppressed and transplant recipients and AIDS patients but the outcome is frequently fatal.Varicella Pneumonia is most common and serious complications and found to be associated with 5%- 15% of cases in adult chickenpox. Risk factors for the progression to pneumonia include Smoking, immunosuppression, pregnancy, older age, and other lung disease. Treatment is a 7-day course of acyclovir is currently recommended for the varicella pneumonia and Varicella zoster associated hepatitis. CONCLUSIONS: - Varicella-zoster virus (VZV) occurs during childhood and is usually a benign self-limited illness in immunocompetent children.- While skin and soft tissue complications are common Varicella Zoster pneumonia and varicella hepatitis are rare complication especially in immunocompromised individual with significant mortality. -Early institution of antiviral medications and supportive care are mainstay of the treatment for VZV pneumonia and hepatitis REFERENCE #1: Frangides CY, Pneumatikos I. Varicella-zoster virus pneumonia in adults: report of 14 cases and review of the literature. Eur J Intern Med. 2004 Oct;15(6):364-370. doi: 10.1016/j.ejim.2004.04.016. PMID: 15522570 REFERENCE #2: Chiner E, Ballester I, Betlloch I, Blanquer J, Aguar MC, Blanquer R, Fernández-Fabrellas E, Andreu AL, Briones M, Sanz F. Varicella-zoster virus pneumonia in an adult population: has mortality decreased? Scand J Infect Dis. 2010 Mar;42(3):215-21. doi: 10.3109/00365540903428166. PMID: 20055724. REFERENCE #3: Kusne S, Pappo O, Manez R, Pazin G, Carpenter B, Fung JJ, Starzl TE. Varicella-zoster virus hepatitis and a suggested management plan for prevention of VZV infection in adult liver transplant recipients. Transplantation. 1995 Sep 27;60(6):619-21. doi: 10.1097/00007890-199509270-00019. PMID: 7570963; PMCID: PMC3082453. DISCLOSURES: No relevant relationships by Binit Aryal No relevant relationships by Chhabilal Bastola No relevant relationships by Chhabilal Bastola No relevant relationships by Danilo Enriquez No relevant relationships by ahmad ali Khan