Led astray by serology

Abstract

A 27-year-old man of South Asian ethnicity presented with abdominal pain, nausea and constipation. Eight months earlier he had undergone myeloablative, haplo-identical, allogeneic stem cell transplantation (SCT) for acute lymphoblastic leukaemia. Immunosuppression had been stopped 4 months before presentation; he had continued prophylactic aciclovir, co-trimoxazole and phenoxymethylpenicillin. He was febrile and abdominal imaging revealed oedematous pancreatitis and non-obstructive cholecystitis. Despite fluids and antibiotics (co-amoxiclav, gentamicin), he deteriorated and two days later, a painless, non-pruritic rash emerged, spreading from the face to trunk and limbs. He also developed profuse diarrhoea, melaena and anaemia. His abdomen was soft with generalised tenderness and active bowel sounds. A diffuse rash affected face, trunk and limbs, sparing palms and soles. Lesions were dark, 1–4 mm haemorrhagic vesicles over an erythematous base. Pigmented, ulcerating lesions were noted over the hard palate. An endoscopy showed multiple gastric ulcers. Methylprednisolone was commenced for possible acute Graft-versus-Host Disease, and disseminated infection was treated empirically with piperacillin-tazobactam, ivermectin and aciclovir. Disseminated varicella zoster virus (VZV) infection was confirmed by identifying VZV viraemia and positive VZV PCR from lesion swabs. Pre- and post-SCT VZV IgG titres were > 150mIU/ml. There was CD4 + lymphopenia (56 x106/L). As no additional cause was identified, the pancreatitis and small bowel inflammation was felt most likely to be due to visceral reactivation of VZV. Take-home messages: 1. VZV reactivation may still occur despite aciclovir prophylaxis. 2. Immune reconstitution post-SCT is highly variable. 3. Seemingly adequate VZV IgG titres do not necessarily prevent infection if there is immunosuppression. Abstract without diagnosis A 27-year-old man of South Asian ethnicity presented with abdominal pain, nausea and constipation. Eight months earlier he had undergone myeloablative, haplo-identical, allogeneic stem cell transplantation (SCT) for acute lymphoblastic leukaemia. Immunosuppression had been stopped 4 months before presentation; he had continued prophylactic aciclovir, co-trimoxazole and phenoxymethylpenicillin.