Purpose

Visceral dissemination of varicella zoster virus (VZV) and herpes simplex virus (HSV) infection in solid organ transplant recipients is a rare but life-threatening condition. 

Methods

We experienced a 49 years old female patient who underwent deceased donor liver transplantation (DDLT) for alcoholic cirrhosis and was succumbed to fulminant herpes viral hepatitis 9 days after the operation.

Results

She was admitted to the hospital 2 months before DDLT due to jaundice and generalized edema. When allocated, she was on CRRT, ventilator and vasopressor support. MELD score was 40. Graft showed less than 5% fatty change. Ischemic time was 506 minutes. On POD 5 generalized skin rash (erythematous papulovesicular lesions with a few central necrosis) developed (Fig.1). Next day, the skin lesions aggravated and diagnostic work up including HSV, VZV serology and PCR, and skin biopsy were performed. And empirically high dose Acyclovir and Voriconazole were given parenterally. However, skin rashes progressed as they coalescent together and darkened in color. AST level jumped from 259 IU/L to 3066 on POD 6. There was no major vascular complication on CT scan. Methyl-PD 500 mg was given daily to cover undetermined acute cellular rejection empirically. However, AST level rose relentlessly to 8398 and 9408 IU/L on the next consecutive days. Liver biopsy was done. She died 9 days after the DDLT. Later, skin biopsy showed herpes infectious disease (Fig. 2) and positive for VZV PCR and negative for HSV type I and II PCR. Liver biopsy revealed acute viral injury (Fig. 3) and positive for VZV PCR and weakly positive for HSV type II PCR. So the authors consider this case as a disseminated Zoster case coinfected with HSV-II manifesting fulminant hepatitis.

Conclusion

In patients without CMV prophylaxis, short term antiviral prophylaxis for HSV also effective against VZV during the immediate post-LT period should be considered.