VISCERAL VARICELLA-ZOSTER AFTER BONE-MARROW TRANSPLANTATION - REPORT OF A CASE SERIES AND REVIEW OF THE LITERATURE

Objectives: Infection with varicella-zoster virus after bone marrow tr ansplantation (BMT) is a common cause of morbidity and mortality. Visc eral involvement with varicella-zoster mag be incorrectly ascribed to graft-versus-host disease, resulting in delayed diagnosis and misguide d therapy. Methods: A 4-yr retrospective chart review was performed to determine the presenting symptoms and clinical outcome of visceral va ricella-zoster virus infection in BMT recipients. Results: Ten BMT rec ipients who subsequently developed visceral varicella-zoster virus inf ection were identified. The mean age at diagnosis was 40 yr (range 27- 56 yr). Primary hematological malignancies were leukemia (N = 7), myel odysplasia (N = 2), and myelofibrosis (N = 1). Bone marrow transplants in affected patients were autologous (N = 2), related allogeneic (N = 5), or matched unrelated allogeneic (N = 3). The mean time interval f rom BMT to symptomatic visceral varicella-zoster virus infection was 1 53 days (range 60-280 days). Presenting symptoms included abdominal pa in in all patients, nausea (60%), fever > 38 degrees C (60%), vomiting (50%), pneumonitis (50%), skin rash (40%), and diarrhea (30%). All pa tients had moderately or profoundly elevated aminotransferases and mos t had elevated pancreatic enzymes (80%). The mean time interval from t he development of abdominal pain to the characteristic skin rash and t hen diagnosis was 6 and 7 days, respectively (range 3-10 and 4-14 days ). Active graft-versus-host disease had previously been documented in five of the eight allogeneic BMT recipients. Immunosuppressive medicat ions were increased at the onset of the abdominal pain in seven of the se eight patients for suspected exacerbation of graft-versus-host dise ase. After recognition of varicella infection, antiviral therapy was p romptly initiated; despite this, mortality was still 50%. Conclusions: Visceral involvement with varicella-zoster virus infection can occur as a late complication after both allogeneic and autologous BMT. In th ese cases, symptoms of severe abdominal pain with associated nausea, v omiting, and diarrhea and elevated liver and pancreatic enzymes preced ed the vesicular skin eruption and were confused with graft-versus-hos t disease. With the increasing application of high-dose chemotherapy f ollowed by stem cell rescue for both hematological and solid tumors, c linicians should be aware of this potentially treatable and often leth al complication. (C) 1998 by Am. Cell. of Gastroenterology.