S2719 A Rare Case of Disseminated Varicella Zoster in a Young Patient With Cirrhosis

Abstract

INTRODUCTION: Herpes zoster, otherwise known as shingles, occurs after reactivation of the dormant, neurotropic, varicella zoster virus (VZV) that lies in the dorsal root ganglia. The typical manifestation consists of self-limiting, painful, vesicular skin lesions that follow a dermatomal pattern. Herpes zoster can present as a disseminated infection in immunocompromised patients (e.g., HIV, malignancy, chronic immunosuppressive drugs) and, very rarely, in immunocompetent individuals. Patients with cirrhosis are deemed to be at high risk for infections as a result of immune dysfunction although a nationwide, population-based study from Taiwan has shown that cirrhosis is not associated with an increased risk for herpes zoster. Furthermore, although there are case reports of post-vaccine primary varicella infection and subsequent dissemination, there appear to be none detailing a dissemination of reactivated varicella zoster in a cirrhotic patient. CASE DESCRIPTION/METHODS: We present a case of a 34 yr old male on no medications, with a twelve year history of heavy alcohol use and decompensated cirrhosis, who was admitted for higher level of care and liver transplant evaluation. Ten days into his admission, vesicular lesions were noted on his left flank. VZV PCR testing showed 438,342 copies/mL. Workup for other infections such as Hepatitis A, B, C and HIV were negative. The patient was initially started on 350 mg IV acyclovir every twelve hours which was subsequently increased to 700 mg IV due to presence of VZV in the ascitic fluid that was concerning for dissemination. Unfortunately, the patient developed multi-organ system failure and passed away. DISCUSSION: This case highlights a rare instance of VZV dissemination in a young patient with cirrhosis who only displayed a cluster of vesicles on his left flank. While VZV dissemination has been known to occur in immunocompromised patients, cirrhotic patients have not usually been considered to be at higher risk for reactivation or dissemination. Our case highlights the importance of early diagnosis and prompt, aggressive management of shingles in patients with cirrhosis to reduce the risk of disseminated VZV and mortality.