(617) An Unusual Case of Fulminant Hemorrhagic Varicella Infection in an Immunocompetent Patient

Introduction: Primary Varicella Zoster Virus (VZV) infection is known to be self-limited. Immunocompromised adults may develop complications. The following is an unusual case of fatal fulminant hemorrhagic VZV infection in a previously healthy adult.

Description: A 62-year-old man, employed at a vegetable market, with non-insulin dependent diabetes (HbA1c 8.3), presented with fever, dyspnea, and a rapidly progressive generalized pruritic rash for two days, following a one-week prodrome of sore throat and mild cough. He was alert and oriented but in significant respiratory distress with HR of 123, BP 98/65 mmHg. Arterial blood gas showed mixed metabolic and respiratory acidosis with pH of 6.92, pCO2 67, HCO3 13.9, lactate 13 mmol/L, PaO2/FiO2 186 and the patient was intubated. Examination was notable for the presence of diffuse maculo-papulo-vesicular rash in various stages of development with some large hemorrhagic vesicles as well as anuria. Leukocyte count was 19, 500/mcL, platelet 77, 000/mcL, creatinine 2.9 mg/dL, ALT 1121, and AST 2189. Chest Xray showed diffuse bilateral infiltrates. He was initiated on continuous renal replacement therapy, vasopressors, Acyclovir, broad-spectrum antibiotics, and hydrocortisone but remained in refractory shock with persistent lactic acidosis (15 mmol/L) and DIC. Peripheral blood PCR was positive for VZV and Parvovirus B19, but VZV IgM and IgG antibodies were negative, indicating lack of immunization. Nasopharyngeal viral screen, human immunodeficiency virus, and all other bacterial cultures remained negative. He had a cardiac arrest, and comfort measures were implemented.

Discussion: We describe VZV infection complicated by pneumonia, hepatitis, DIC, large hemorrhagic skin lesions, refractory shock, and renal failure in a non-immunized immunocompetent adult. Such fatal fulminant hemorrhagic disease is almost exclusive to immunocompromised hosts. The authors consider this a case of academic interest, emphasizing the possibility of life-threatening VZV infection in healthy adults and the significance of vaccination with special consideration for high-risk adults working in crowded settings. Given their high mortality rate, community physicians and intensivists must have a low index of suspicion and be prompt with the diagnosis and treatment of VZV complications.