A 21-day course of intravenous acyclovir led to full neurologic recovery in a 61-year-old immunocompromised woman with disseminated VZV viremia, multisystem involvement, and cardiac arrest.
Case Report (n=1)
Disseminated VZV in immunocompromised patients can present atypically with shock and cardiac arrest, requiring high clinical suspicion and prompt antiviral therapy for favorable outcomes.
Abstract Introduction Disseminated varicella-zoster virus (VZV) infection is a rare but life-threatening condition, typically occurring in immunocompromised individuals. Confirmed VZV viremia is uncommon and often associated with severe systemic involvement, including multiorgan dysfunction and high mortality. Early recognition and antiviral therapy are critical to improving outcomes. Case Presentation A 61-year-old woman with rheumatoid arthritis on chronic prednisone and hydroxychloroquine, type 2 diabetes mellitus, and hypertension was found unresponsive at home after several days of immobility. On arrival, she was acutely encephalopathic with leukocytosis (WBC 13.1 ×109/L), acute kidney injury (creatinine 2.83 mg/dL), elevated troponin I (618 ng/L), and anion gap metabolic acidosis. While undergoing evaluation, she developed pulseless electrical activity (PEA) cardiac arrest, achieving return of spontaneous circulation after one round of CPR and epinephrine. A second bradycardic arrest followed, again with successful resuscitation. She was intubated and admitted to the ICU for post-cardiac arrest care and septic shock requiring vasopressors. Within hours, grouped vesicular lesions appeared in a thoracic dermatomal pattern. Empiric intravenous acyclovir was initiated and later confirmed appropriate by positive blood VZV PCR, establishing viremia. Brain MRI revealed small acute infarcts in the left cerebellar and frontal lobes with right frontal cortical signal abnormalities, concerning for central nervous system involvement. Transthoracic echocardiography demonstrated preserved left ventricular ejection fraction (55-60%) and elevated right ventricular systolic pressure (53 mmHg). She developed anuric renal failure requiring continuous renal replacement therapy. The patient was extubated on hospital day six with full neurologic recovery and completed a 21-day course of intravenous acyclovir. Discussion Disseminated VZV in immunocompromised hosts can present atypically, sometimes preceding the appearance of a rash. In this case, the combination of chronic corticosteroid use and diabetes predisposed to viral reactivation and systemic dissemination. The patient’s cardiac arrest likely resulted from a combination of septic shock, metabolic derangements, and possible viral myocarditis. Conclusion Confirmed VZV viremia with multisystem involvement is exceedingly rare but carries significant morbidity and mortality. This case highlights the importance of maintaining a high index of suspicion for disseminated VZV in immunocompromised patients presenting with unexplained encephalopathy or shock. Prompt antiviral therapy and multidisciplinary critical care are essential for improving outcomes. This abstract is funded by: None
Janajrah et al. (Fri,) conducted a case report in Disseminated varicella-zoster virus infection (n=1). Intravenous acyclovir was evaluated. A 21-day course of intravenous acyclovir led to full neurologic recovery in a 61-year-old immunocompromised woman with disseminated VZV viremia, multisystem involvement, and cardiac arrest.