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Image of the Month Esophageal Chicken Pox in a Patient on Immunosuppressive Therapy SUSANA DE LA RIVA, MIGUEL MUÑOZ–NAVAS, and IAGO RODRÍGUEZ–LAGO Gastroenterology Department, Endoscopy Unit, Clínica Universidad de Navarra, Pamplona, Navarra, Spain A 33-year-old man previously diagnosed with pemphigus vulgaris was admitted to our hospital. He was on predni- sone and azathioprine. He presented with a 48-hour history of fever, intense epigastric pain, odynophagia, heartburn, nausea, and uncontrollable vomiting. In the previous 24 hours, vesicular lesions had appeared on his scalp and face with subsequent extension to his trunk and abdo- men. On physical examination there were multiple meliceric peri- oral crusts and also 3-mm round ulcers in the oral mucosa. Because of the clinical suspicion of chicken pox with systemic dissem- ination, he was admitted for study and treatment in our center. Blood tests showed a progressive increase of aspartate ami- notransferase and alanine aminotransferase levels with a max- imum peak of 2.410 IU/L (range, 1–25 IU/L) and 1.410 IU/L (range, 1–29 IU/L), respectively. These findings, together with an increase in creatine phosphokinase, were attributed to myo- carditis. We cannot exclude some degree of liver involvement that could have contributed to the increase in aspartate ami- notransferase and alanine aminotransferase enzyme levels. A chest radiograph showed multiple foci of increased density in both lung fields with a pattern suggestive of viral infection. Upper endoscopy showed multiple vesicular lesions covered with fibrin on the tongue, pharynx, and larynx, with involvement of one of the vocal cords (Figure A). All along the esophagus there were many fibrinoid punctate lesions with other heme-containing vesicles (Figure B). Multiple biopsy specimens were taken for his- tologic study. Histologic examination showed signs of erosive esophagitis and the presence of multinucleated cells with nuclear acidophilic inclusion bodies that gave them a frosted glass appear- ance (Figure C), suggestive of varicella zoster virus (VZV) infection. He was diagnosed with esophageal chicken pox, and specific treatment was started with intravenous acyclovir and a progres- sive decrease of immunosuppressive drugs. The patient was discharged 14 days after admission with resolution of skin lesions and significant improvement of digestive symptoms. Visceral dissemination of VZV is a severe complication of this infection that usually occurs in adults in immunosuppressed states. Although cerebral and pulmonary involvement are rela- tively common, the gastrointestinal tract affectation rarely has been reported in the literature. There are only 4 cases of diges- tive involvement of VZV in the literature: a case of pancreatitis associated with VZV infection, an episode of upper gastrointes- tinal bleeding caused by the presence of esophageal ulcer- ations, 1 gastrointestinal bleeding as a result of involvement of the small intestine, 2 and a gastric perforation by ulceration attributed to viral infection. 3 Visceral disease almost always occurs after skin lesions have been noticed. However, there have been some reports of dissemi- nated VZV without any cutaneous manifestations, which can delay the clinical diagnosis and the start of specific treatment. In our patient, the visceral involvement with digestive symp- toms occurred before the appearance of the classic skin rash. However, the cutaneous lesions at the time of admission al- lowed an adequate clinical suspicion that enabled the initiation of early treatment and a successful outcome. References 1. Lawn SD, Venkatesan P. Chickenpox oesophagitis and haematem- esis in an immunocompetent adult. J Infect 2002;44:206. 2. Sherman RA, Silva J Jr, Gandour-Edwards R. Fatal varicella in an adult: case report and review of the gastrointestinal complications of chicken pox. Rev Infect Dis 1991;13:424 – 427. 3. Paret G, Yahav J, Cohen O, et al. Varicella and perforation of the stomach. J Pediatr Gastroenterol Nutr 1990;10:121–125. Acknowledgments The authors would like to thank Dr Sola for his important contribu- tion to the diagnosis and the anatomopathologic study figures. Conflicts of interest The authors disclose no conflicts. © 2013 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2012.06.025 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2013;11:xxxiii
