S5470 When Chickenpox Turns Deadly: Acute Hepatitis and Multi-Organ Failure From Primary VZV in an Immunocompetent Adult

Introduction: Disseminated varicella zoster virus (VZV) resulting in hepatitis and central nervous system (CNS) involvement is exceptionally rare in immunocompetent patients. Varicella pneumonitis as a complication of chickenpox is well described in adults. Most cases of dissemination in literature have occurred in immunocompromised adults. We present a case of hepatitis and multi-organ failure from primary VZV infection in an immunocompetent adult that led to significant morbidity and near mortality. Case Description/Methods: A 55-year-old immunocompetent woman with prior treated hepatitis C presented with epigastric pain, nausea, and vomiting and was found to have CBD dilation and a stone on MRCP for which she underwent an ERCP which was uneventful. On hospital day 3, she developed a diffuse vesicular rash, fevers, and severe abdominal pain in the background of her husband having a primary VZV infection 3 weeks prior, for which valacyclovir was started orally. She had no prior history of immunosuppression, and her testing (including HIV) was suggestive of an immunocompetent adult. She was not vaccinated for primary VZV or shingles. She subsequently developed an acute liver injury, worsening mental status requiring intubation and ICU transfer. Intravenous (IV) acyclovir as well as N-acetylcysteine (NAC) was started. Testing of the rash and lumbar puncture confirmed VZV polymerase chain reaction (PCR) positive, which confirmed disseminated VZV infection. On admission, her liver function was within normal limits with no prior chronic liver disease. Liver injury peaked on day 4 (aspartate aminotransferase 860 U/L, alanine aminotransferase 746 U/L, alkaline phosphatase 207 U/L, total bilirubin 2.3 mg/dL, international normalized ratio 1.43, Graph 1 for trend). Her clinical course improved upon starting IV acyclovir, and a liver biopsy was deferred. She was extubated after 96 hours. Liver enzymes normalized on day 16 of admission. Discussion: Disseminated primary VZV is exceedingly rare in immunocompetent adults but can lead to fulminant hepatitis, encephalitis, and multiorgan failure. Although she had a history of hepatitis C that was treated, she had no other infections suggestive of an immunocompromised state. The collateral history from her husband was crucial in clinching the diagnosis. This also highlights the need for early viral PCR testing (VZV, herpes simplex virus) of rashes in adults with unexplained hepatitis and neurological symptoms, as well as prompt initiation of IV acyclovir and NAC which may improve outcomes. The rapid progression with high morbidity underscores the importance of prompt recognition and maintaining a high index of suspicion.