Visceral Varicella-Zoster Virus Infection Presenting with Severe Abdominal Pain without a Rash in a Patient with Psoriatic Arthritis Treated with Infliximab Biosimilar and Steroids: A Case Report

Abstract

Visceral herpes zoster following reactivation of dormant varicella-zoster virus can rarely occur, usually in highly immunosuppressed patients, and may present with abdominal pain without the relevant rash. In the absence of skin manifestations, diagnosis of visceral herpes zoster is extremely difficult, while computed tomography may reveal isolated periarterial fat stranding. We describe a rare case of visceral herpes zoster in a medically immunocompromised adult with psoriatic arthritis, who presented with acute abdomen, was diagnosed based on computed tomography findings and subsequent serum polymerase chain reaction results, and was appropriately treated with an uneventful recovery. This case underlines the significance of considering varicella-zoster virus infection as a cause of severe abdominal pain even in the absence of rash in this setting, and highlights the potential role of appropriately performed computed tomography in such unusual and complex cases, where early diagnosis and initiation of treatment is extremely important for a favorable outcome.

Keywords: Visceral varicella zoster; abdominal pain; computed tomography; immunosuppression; periarterial fat stranding.

Figure 1.

CT scan following intravenous contrast administration, split-bolus excretory-portal phase. (A) Axial slice shows the superior mesenteric artery containing a hypoenhancing line (arrowhead) and surrounded by perivascular fat stranding (arrow). (B) Coronal reconstruction shows a short line at the upper aspect of the lumen (arrowhead) and thickening of the adjacent wall (arrow). Findings were initially interpreted as dissection.

Figure 2.

CT scan following intravenous contrast administration, portal phase. (A) Axial slice shows the enhancing superior mesenteric artery (arrowhead) with an intact smooth lumen, without evidence of dissection. Note perivascular fat stranding as circumferential increased density of adjacent fat (arrow). (B) Maximum intensity projection reconstruction in the coronal plane shows the extent of perivascular fat stranding (arrow) which was appreciated as progressive compared to the initial scan and situated around the normal lumen of superior mesenteric artery and adjacent celiac artery (arrowhead).

Figure 3.

A non-pruritic macular rash emerged on the patient’s back on the second day of hospitalization, without further evolution.