Severe varicella in an immunocompromised adult presenting with abdominal pain

To the editor,

A 65-year-old woman was admitted to our hospital because of abdominal and right flank pain. She had undergone a splenectomy 5 years before for non-Hodgkin's lymphoma and a cycle of chemotherapy 2 months before her admission.

On physical examination, the patient was afebrile, and her vital signs were normal. Cardiac and pulmonary examination findings were normal. An abdominal examination revealed normal bowel sounds with diffuse tenderness localized to the right half of the abdomen, but with no guarding. There were no lesions on the skin or mucosa.

Results of initial blood tests—complete blood cell count, liver enzyme levels, amylase, and blood chemistries—were in the normal ranges. The chest on radiography appeared normal. Radiography of the abdomen without contrast enhancement showed distention of the ascending colon, and contrast-enhanced radiography showed no obstruction.

The distention of the transverse colon and cecum increased progressively, and on the 4th day a decompressive cecostomy was performed. On the day after, high fever (40°C [104°F]) developed, and the patient became obtunded. She was transferred to the intensive care unit for the treatment of possible sepsis, and antibiotic therapy with imipenemcilastatin sodium and tobramycin sulfate was initiated. Her neurologic condition deteriorated progressively, and on the 10th day of hospitalization she required intubation and mechanical ventilation.

A vesiculopapular rash developed, beginning on the 7th day. This started on the trunk and face and then spread to the entire surface of the patient's body, sparing the mucous membranes. The vesicular rash became progressively hemorrhagic and purpuric. Her platelet count fell, and the result of coagulation tests became abnormal.

An enzyme-linked immunosorbent assay for herpes zoster virus showed a positive result for IgM and a titer of 640 IU/L for IgG on the 15th day. A regimen of acyclovir was started. The titer of IgG increased to 3,300 IU/L on the 25th day, and hemofiltration was performed for progressive azotemia. On the 29th day of hospitalization, the patient died.

Severe varicella is a well-known complication in immunocompromised children, and intense abdominal pain is often the first symptom of dissemination. We searched the medical literature for this syndrome in adults with MEDLINE using the search terms “varicella,” “immunocompromised host,” and “abdominal pain” and the option “related articles” for the articles found. In 2 articles, adult immunocompromised patients with varicella presented with abdominal pain as their major complaint.^1,2 In all the cases described, the symptom at presentation was abdominal pain. Fever, the typical mucocutaneous rash, diffuse visceral dissemination, and intravascular coagulation began some days later.

Varicella should be considered in the differential diagnosis of abdominal pain in all immunocompromised patients, particularly when the cause is not obvious. Acyclovir therapy should be started as soon as the clinical picture shows the typical manifestation of the disease because surgery in immunocompromised patients is poorly tolerated, and prompt initiation of therapy with acyclovir can be life-saving.