A Case of Varicella Zoster Hemorrhagic Gastritis

Abstract

Introduction: Hemorrhagic gastritis secondary to Varicella zoster virus (VZV) is rarely identified in immunocompromised patients, and we report such a case from our experience. An 82-year-old female with chronic lymphoid leukemia receiving chemotherapy, presented with 1 week of anorexia, abdominal pain, nausea and vomiting. Lab evaluation was significant only for thrombocytopenia, and abdominal CT scan was unrevealing. Her symptoms persisted despite hydration and pain control, and on hospital day 5 she developed worsening thrombocytopenia with transaminemia and leukocytosis. Viral hepatitis panel including HSV, CMV and EBV was negative, as was an abdominal ultrasound with doppler. An upper endoscopy performed to evaluate her symptoms revealed small, hemorrhagic, irregular shallow ulcerations and erosions throughout the stomach (Figure 1A). A diffuse vesicular rash developed on hospital day 10, and acyclovir was initiated empirically. Multi-organ failure rapidly ensued, and care was withdrawn. The endoscopic biopsies later revealed epithelial hemorrhage, ischemia and nuclear viral inclusions with a strongly positive immunohistochemical stain for VZV, consistent with acute hemorrhagic gastritis due to VZV (Figure 1B). Viral swab of a skin lesion was positive for VZV by PCR.Figure 1: (A) Hemorrhagic, ecchymotic shallow ulcerations and erosions with exudate. (B) Immunohistochemical stain for VZV demonstrates diffuse and strong positivity within viral inclusions.Discussion: To our knowledge, this is one of a few cases of VZV hemorrhagic gastritis confirmed by endoscopic biopsy and PCR of cutaneous lesions. Reactivation of VZV is common in immunocompromised patients, usually presenting as a cutaneous eruption of vesicles. Rarely, visceral and gastric involvement can occur, usually concurrent with a hematologic malignancy and disseminated cutaneous involvement. The vesicular eruption can be absent initially and be first observed up to 10 days after abdominal symptoms develop. Presentation of visceral VZV is non-specific and may be characterized by nausea, vomiting, and abdominal pain with possible development of gastrointestinal hemorrhage, pancreatitis and hepatitis. While endoscopic evaluation is often unrevealing, gastrointestinal mucosal involvement can occur in the form of gastric ulcerations or punctate hemorrhages. Treatment is with antivirals. A high clinical suspicion is important to recognize this condition early in the proper clinical setting, as mortality rate can be 40-50%.