Abdominal Pain Before Rash in Immunocompromised Patients: A Narrative Review of a Visceral Disseminated Varicella-Zoster Virus Infection

Visceral disseminated varicella-zoster virus (VZV) infection is an uncommon, but potentially life-threatening complication in immunocompromised patients and it may initially present with severe abdominal pain before any rash appears. This narrative review, supported by a structured PubMed search through March 2026, aimed to characterize such abdominal-pain-first presentations and identify practical clues for making earlier diagnosis. We integrated the findings from a previously published illustrative case meeting the review focus. Across the available literature, recurrent features included severe abdominal pain disproportionate to the abdominal findings, a delayed or absent rash at presentation, limited or non-diagnostic computed tomography findings, and periarterial fat stranding around the celiac artery or superior mesenteric artery in some reports. In immunocompromised patients with severe unexplained abdominal pain, a visceral disseminated VZV infection should be included in the differential diagnosis. Repeated skin examinations, early blood VZV-DNA testing, prompt intravenous aciclovir, and a reduction of immunosuppression when feasible may facilitate both earlier recognition and treatment.