Simultaneous Occurrence of Varicella Zoster Virus-Induced Pancreatitis and Hepatitis in a Renal Transplant Recipient: A Case Report and Review of Literature

Abstract

Introduction: Gastrointestinal complications are common after renal transplantation, including oral lesions, esophagitis, gastritis, diarrhea, and colon carcinoma. The differential diagnosis is difficult in this scenario because multiple factors such as drugs, infections, and preexisting gastrointestinal disease come into play.Case Presentation: We report a case of varicella zoster virus-induced pancreatitis and hepatitis in a renal transplant recipient. The patient underwent renal transplantation 3 years earlier and now presented with severe pain in the epigastrium radiating to his back and had raised serum lipase levels and skin lesions characteristic of varicella. Liver enzyme levels were also elevated. He was started on a regimen of acyclovir. His pain improved in 24 hours, and liver enzyme levels returned to normal in 48 hours.Discussion: There is a paucity of literature on the simultaneous occurrence of varicella zoster virus-induced hepatitis and pancreatitis in both immunocompetent and immunocompromised patients. Our case highlights the gastrointestinal complications of varicella infection in immunocompromised patients that may precede the characteristic dermatologic manifestations, and the fact that rarely both hepatitis and pancreatitis may be seen.

Fatal disseminated visceral varicella zoster virus infection in a renal transplant recipient

“…17 Both patients had elevated liver transaminases and pancreatic enzymes, and in both cases their symptoms and biochemical abnormalities resolved quickly with intravenous acyclovir. 16,17 The very late onset of the VZV rash, occurring 11 days after the onset of abdominal symptoms, may have contributed to the fatal outcome in our patient. The absence or late onset of an indicative rash can lead clinicians to consider alternative diagnoses for hepatitis, such as acalculous cholecystitis or drug toxicity.…”

“…In a study of disseminated VZV among 56 adult renal transplant recipients, hepatitis was a complication in 31% and pancreatitis in only 4% . One recent case from India involved a renal transplant recipient presenting with a week of abdominal pain and 4 days of a vesicular rash . Another case from the Netherlands described an autologous stem cell transplant recipient presenting with abdominal pain, who developed a vesicular rash in hospital and was found endoscopically to have esophageal and gastric ulceration .…”

“…9 One recent case from India involved a renal transplant recipient presenting with a week of abdominal pain and 4 days of a vesicular rash. 16 Another case from the Netherlands described an autologous stem cell transplant recipient presenting with abdominal pain, who developed a vesicular rash in hospital and was found endoscopically to have esophageal and gastric ulceration. 17 Both patients had elevated liver transaminases and pancreatic enzymes, and in both cases their symptoms and biochemical abnormalities resolved quickly with intravenous acyclovir.…”

Pancreatitis in Solid Organ Transplant Patients: A Review of the Literature

“…Risk factors associated with acute pancreatitis in this population, include co-morbidities (such as PCKD and impaired lipid metabolism [30]), peritoneal dialysis [35], hypercalcemia [33,36], infectious causes (such as cytomegalovirus or varicella zoster virus) [30,33,37,38], and immunosuppressive mediations [30,32,33,[39][40][41][42][43][44]. Multiple studies describe an increased risk of acute pancreatitis with cyclosporine or corticosteroids [32,39,40].…”

Atypical Reactivation of Varicella Zoster Virus Associated with Pancreatitis in a Heart Transplant Patient

“…Among solid organ transplant recipients who are immunosuppressed, specific etiologies such as steroid use, azathioprine, and cytomegalovirus (CMV) reactivation have also been reported [ 1 ]. While only a few cases of pancreatitis in renal transplant patients have been attributed to VZV, some patients became critically ill and died from disseminated disease [ 4 ]. Here, we present the first reported case of acute pancreatitis associated with atypical reactivation of VZV presenting as a varicella-like rash in a heart transplant recipient.…”