2416 A Case of Fever, Rash, and Abdominal Pain in an Immunocompromised Host

Abstract

INTRODUCTION: Varicella Zoster Virus (VZV) is a DNA virus that leads to two clinical syndromes: varicella (primary) and herpes zoster or shingles (secondary). Disseminated infection is most common in immunocompromised hosts and can lead to multi-organ involvement including hepatitis, pneumonitis, encephalitis and others. Here, we describe a case of a young woman with human immunodeficiency virus (HIV) and primary varicella infection leading to VZV hepatitis. CASE DESCRIPTION/METHODS: A 35-year-old woman presented with a 1-week history of fevers, right upper quadrant and epigastric pain, and a non-pruritic, non-painful rash. Her past medical history was significant for a diagnosis of HIV 5 years prior, not currently on treatment. Upon presentation, vital signs were within normal limits except for a fever of 38.8°C. Physical examination was notable for multiple crusted erosions and papules present on her face, trunk and extremities (Figures 1 and 2). Laboratory evaluation was notable for alanine aminotransferase level 291 U/L, aspartate aminotransferase level 260 U/L, alkaline phosphatase level 135 U/L, total bilirubin 0.4 mg/dL, leukocytes 8 × 109/L, and platelet count 132 × 109/L. CD4 count was 118 cells/mcL and HIV-1 RNA 4,120,000 copies/mL. Computed tomography abdomen/pelvis demonstrated diffuse heterogeneity of the hepatic parenchyma (Figure 3). She underwent liver biopsy and pathology demonstrated hepatic parenchyma with portal and lobular inflammation but no necrosis. VZV polymerase chain reaction (PCR) from the liver and facial lesion swab returned positive. She was treated with 4 days of IV acyclovir with improvement in her fevers and transaminitis and then transitioned to oral valacyclovir. HAART was also initiated two days after the start of IV acyclovir. DISCUSSION: The differential for fever and widespread rash in an immunocompromised individual is broad, and includes disseminated herpes simplex virus, VZV, secondary syphilis, disseminated gonococcal infection, parvovirus, cryptococcosis and others. While uncomplicated VZV can be treated with supportive care or oral antivirals, such as acyclovir, valacyclovir, or famciclovir, an immunocompromised host with disseminated VZV should typically be admitted to the hospital for intravenous acyclovir. Biopsy proven VZV hepatitis is rare and is associated with a high mortality. Notably, our patient's VZV IgM and IgG were negative, indicating the need for a high degree of suspicion if the clinical scenario is consistent with VZV.