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Leena M, Ville V, Veli-Jukka A. Visceral varicella zoster virus infection after stem cell transplantation: a possible cause of severe abdominal pain. Scand J Gastroenterol 2006; 41:242-4. [PMID: 16484131 DOI: 10.1080/00365520500328113] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Reactivation of varicella zoster virus (VZV) is a common event after stem cell transplantation (SCT). When activated in the abdominal cavity, the infection may be life threatening. Visceral presentation with VZV infection is uncommon, although probably an under-diagnosed event in post-SCT patients. The interval from onset of abdominal pain to the development of skin eruptions may delay the initiation of specific antiviral therapy and symptoms may be incorrectly diagnosed as surgical disease or graft-versus-host disease. We describe the case of a 53-year-old man who had undergone stem cell autograft for multiple myeloma and developed visceral VZV infection with hepatitis, melaena and subileus 7 months later.
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Affiliation(s)
- Mattila Leena
- Department of Medicine, Division of Infectious Diseases, Helsinki University Central Hospital, Finland.
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52
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Abstract
AbstractViral infections are important causes of morbidity and mortality for patients with a hematological malignancy. However, the true incidence and consequences of viral infections for these patients who undergo conventional nontransplant therapy are poorly defined. The difference in incidence and outcome of viral infections among patient groups is wide, but dependent upon the intensity and duration of T-cell–mediated immune suppression. Infections caused by cytomegalovirus (CMV), herpes simplex virus (HSV), varicella-zoster virus (VZV), respiratory syncytial virus (RSV), parainfluenza viruses and influenza viruses have been intensely studied, yet newly recognized aspects of these viral infections including late CMV infection; the emergence of new viral pathogens (human herpesvirus-6, BK virus, adenovirus, and human metapneumovirus); the development of molecular diagnostic techniques, and the potential of new agents for viral prophylaxis (maribavir), or preemptive therapy (valganciclovir) form the basis of this review. Well-designed prospective studies are needed to better clarify the spectrum of these viral infections and develop effective prevention and treatment strategies. Yet the increased use of agents like alemtuzumab that induce profound T-cell depletion demands that we develop a better understanding of viral infections that occur in patients with hematological malignancy who receive nontransplant therapy.
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Affiliation(s)
- James C Wade
- Medical College of Wisconsin, 9200 W. WI Ave., FEC 3963A, Milwaukee WI 53226, USA.
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53
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Mantadakis E, Anagnostatou N, Danilatou V, Markaki EA, Spanaki AM, Briassoulis G, Kalmanti M. Fulminant hepatitis due to varicella zoster virus in a girl with acute lymphoblastic leukemia in remission: report of a case and review. J Pediatr Hematol Oncol 2005; 27:551-3. [PMID: 16217259 DOI: 10.1097/01.mph.0000183272.30570.09] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The authors describe a 4-year-old girl with acute lymphoblastic leukemia in remission who developed fulminant hepatic failure due to varicella-zoster virus (VZV). Diagnosing VZV visceral infection in immunocompromised patients is often difficult due to atypical clinical presentation with few or no skin lesions and severe abdominal or back pain. Prompt initiation of empirical treatment with acyclovir and VZV immunoglobulin pending results of the serum polymerase chain reaction for VZV is warranted in this clinical setting.
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Affiliation(s)
- Elpis Mantadakis
- Department of Pediatric Hematology/Oncology, University Hospital of Heraklion, Heraklion, Crete, Greece
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54
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Al-Anazi KA, Al-Jasser AM, Evans DAP. Effect of varicella zoster virus infection on bone marrow function. Eur J Haematol 2005; 75:234-40. [PMID: 16104880 DOI: 10.1111/j.1600-0609.2005.00504.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Most viral infections are known to exert adverse effects on bone marrow function. However, certain viruses have recently been found to be therapeutically beneficial in the treatment of some malignant disorders. METHODS AND MATERIALS A retrospective study was conducted at the Armed Forces Hospital, Riyadh, Saudi Arabia. The changes in the hematological parameters following varicella-zoster virus (VZV) infection in patients with a variety of hematological disorders were compared with those in a control group having the same spectrum of disorders and treated in the same unit over the same period of time but never had VZV infection. Both groups of patients received the same treatment protocols for their primary hematological disorders. Definitive treatment (DT) such as chemotherapy alone, anti-thymocyte globulin or bone marrow transplant was also employed in the management of patients belonging to both groups. RESULTS White blood cell counts, platelet counts and hemoglobin concentrations in the study group started to increase 40 d after chickenpox or herpes zoster infection and these increases lasted for periods as long as 1050 d. The changes in platelet counts were more pronounced than those in other hematological parameters. There was a significant difference (P < 0.0001) between the two groups of patients in the values of platelet counts achieved between 280 and 1050 d after DT (mean platelet count: 262 x 10(9)/L in the study group vs. 180 x 10(9)/L in the control group, median: 288.17 x 10(9)/L in the study group vs. 180 x 10(9)/L in the control group, range: 102 to 415 x 10(9)/L in the study group vs. 26 to 365 x 10(9)/L in the control group of patients). Compared to the control group, the study group of patients achieved their maximum blood counts much earlier after DT. The maximum leucocytic count was achieved at a mean duration of 269.21 d in the study group and 349.61 d in the control group. The maximum hemoglobin level was achieved at a mean duration of 319.5 d in the study group and 402.6 d in the control group. The maximum platelet count was achieved at a mean duration of 271.4 d in the study group and 318.9 d in the control group of patients. CONCLUSION VZV may behave differently from other members of the herpes group of viruses e.g. human cytomegalovirus and Epstein-Barr virus. Our observations suggest that VZV infection causes stimulation of bone marrow activity.
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Affiliation(s)
- Khalid Ahmed Al-Anazi
- Section of Adult Haematology and Bone Marrow Transplant, King Faisal Cancer Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
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55
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Vinzio S, Lioure B, Enescu I, Schlienger JL, Goichot B. Severe abdominal pain and inappropriate antidiuretic hormone secretion preceding varicella-zoster virus reactivation 10 months after autologous stem cell transplantation for acute myeloid leukaemia. Bone Marrow Transplant 2005; 35:525-7. [PMID: 15640814 DOI: 10.1038/sj.bmt.1704814] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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56
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Okamoto S, Yoshikawa T, Ihira M, Suzuki K, Shimokata K, Nishiyama Y, Asano Y. Rapid detection of varicella-zoster virus infection by a loop-mediated isothermal amplification method. J Med Virol 2005; 74:677-82. [PMID: 15484264 DOI: 10.1002/jmv.20223] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The reliability of varicella-zoster virus (VZV) loop-mediated isothermal amplification (LAMP) was evaluated for rapid diagnosis of viral infection. VZV-specific primers only amplified VZV DNA; no LAMP products were observed in reactions performed with other viral DNA templates. The specificity of this method was confirmed by two independent determinations, agarose gel electrophoresis and a turbidity assay. The sensitivity of VZV LAMP, determined by agarose gel electrophoresis, were 500 copies/tube. Detection using the turbidity assay, however, gave a sensitivity of 1,000 copies/tube. After these initial validation studies, reliability of VZV LAMP was evaluated for the detection of viral DNA in clinical specimens. Thirty-two swab samples collected from patients with vesicular skin eruptions were tested for VZV DNA. VZV was confirmed in sample numbers 10-32 by VZV real-time PCR, a previously established technique. VZV LAMP products were detected using turbidity from samples 13 to 32 (sensitivity; 87.0%, specificity; 100%, positive predictive value; 100%, negative predictive value; 75%). Although low levels of VZV DNA could be detected in the three samples exhibiting divergent results (samples numbers 10-12), no VZV LAMP product was detected in these samples, indicating a higher detection limit for this assay. Requirement of a DNA extraction step in the VZV LAMP method was examined in next experiment. The turbidity assay detected a VZV LAMP product in all of the 20 positive swab samples (samples numbers 13-32), regardless of DNA extraction.
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Affiliation(s)
- Souki Okamoto
- Department of Medicine, Division of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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57
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Abstract
UNLABELLED Varicella zoster virus infection often will not present in the characteristic dermatomal distribution of vesicles in patients who have undergone bone marrow transplantation. We cared for a 51-yr-old man with severe abdominal pain after bone marrow transplantation for non-Hodgkin's lymphoma. The diagnosis of varicella zoster was not entertained until he developed a diffuse vesicular rash several days after the onset of pain. We report this case to alert others who may be consulted regarding pain management options for similar oncology patients. IMPLICATIONS We report a patient with lymphoma, prior bone marrow transplant, and acute visceral pain for whom IV opioids in large doses proved inadequate. An interventional pain management technique was considered until characteristic varicella vesicles appeared over the patient's trunk. We report this case to alert others who treat oncology patients that the diagnosis of visceral zoster should be considered when patients who have undergone bone marrow transplantation present with severe visceral pain.
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Affiliation(s)
- Jacqueline M Hyland
- From the Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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58
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Ishizaki Y, Tezuka J, Ohga S, Nomura A, Suga N, Kuromaru R, Kusuhara K, Mizuno Y, Kasuga N, Hara T. Quantification of circulating varicella zoster virus-DNA for the early diagnosis of visceral varicella. J Infect 2003; 47:133-8. [PMID: 12860147 DOI: 10.1016/s0163-4453(03)00004-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Varicella zoster virus (VZV)-DNA was quantified in peripheral blood of 2 patients with visceral varicella due to endogenous reactivation. An 18-year-old male contracted varicella following the courses of chemotherapy for T cell lymphoma. Another 18-year-old male suffered from varicella 16 months after the complete engraftment of hematopoietic stem cell transplantation. Both patients had past VZV infection, but no recent contact with the disease. Paralytic ileus and ascites preceded the skin lesions. Quantitative real-time polymerase chain reaction revealed >200 copies of VZV per 1 ml of whole blood before or at the time when cropping vesicles emerged. The viral load reflected their prolonged clinical courses. Similar levels of VZV-DNA were detected in primary varicella patients, but not in herpes zoster patients or immunocompromised children without varicella or zoster. Quantitative monitoring of circulating VZV-DNA may be useful for the diagnosis and assessing the treatment response of visceral varicella in immunocompromized hosts.
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Affiliation(s)
- Yoshito Ishizaki
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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59
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Nedellec G, Bauduceau O, Amadou S, Foissaud V, Souleau B, Galoo E, Nicand E, de Revel T. Syndrome douloureux abdominal précédant un zona généralisé chez un immunodéprimé. Med Mal Infect 2003. [DOI: 10.1016/s0399-077x(03)00182-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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60
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Chen JJ, Gershon AA, Li ZS, Lungu O, Gershon MD. Latent and lytic infection of isolated guinea pig enteric ganglia by varicella zoster virus. J Med Virol 2003; 70 Suppl 1:S71-8. [PMID: 12627492 DOI: 10.1002/jmv.10325] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Varicella zoster virus (VZV) has been demonstrated to infect guinea pig enteric neurons in vitro. Latent infection of isolated enteric neurons is established when the cultures predominantly consist of neurons and they are exposed to cell-free VZV. Neurons harboring latent infection survive for weeks in vitro and express mRNA encoding ORFs 4, 21, 29, 40, 62, and 63, but not 14(gC) or 68 (gE) (although DNA encoding the glycoproteins is present). The expressed proteins are the same as those that are also expressed in human sensory neurons harboring latent VZV. In addition to mRNA, the immunoreactivities of ORFs 4, 21, 29, 62, and 63 can be detected. ORF 62 and 29 proteins are cytoplasmic and not intranuclear. VZV does not preferentially infect and/or become latent in intrinsic enteric primary afferent neurons indicating that the virus is latent in these neurons. Lytic infection occurs when mixed cultures of neurons and non-neuronal cells of the bowel wall are exposed to cell-free VZV or when isolated enteric neurons are exposed to cell-associated VZV. When lytic infection occurs, enteric neurons die within 48 hr. Prior to their death, neurons express VZV glycoproteins, including gE and gB, and ORF 62 and 29 proteins are intranuclear. This new animal model should facilitate studies of VZV latency and the efficacy of therapies designed to prevent VZV infection, latency, and reactivation.
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Affiliation(s)
- Jason J Chen
- Department of Anatomy and Cell Biology, Columbia University of Physicians and Surgeons, 630 West 168th Street, New York, NY 10032, USA.
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61
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McIlwaine LM, Fitzsimons EJ, Soutar RL. Inappropriate antidiuretic hormone secretion, abdominal pain and disseminated varicella-zoster virus infection: an unusual and fatal triad in a patient 13 months post Rituximab and autologous stem cell transplantation. CLINICAL AND LABORATORY HAEMATOLOGY 2001; 23:253-4. [PMID: 11683787 DOI: 10.1046/j.1365-2257.2001.00397.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report a case of varicella-zoster virus (VZV) infection associated with severe abdominal pain, inappropriate antidiuretic hormone (ADH) secretion (SIADH) and death, 13 months post-autologous peripheral blood stem cell transplantation (PBSCT). This unusual clinical triad has been reported twice in the setting of allogeneic bone marrow transplantation, however it has not been reported after autologous transplantation and never so long after transplantation. We speculate as to why this occurred, as early recognition might have altered the clinical outcome.
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Affiliation(s)
- L M McIlwaine
- Department of Haematology, Western Infirmary, Glasgow, UK
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62
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Müller I, Aepinus C, Beck R, Bültmann B, Niethammer D, Klingebiel T. Noncutaneous varicella-zoster virus (VZV) infection with fatal liver failure in a child with acute lymphoblastic leukemia (ALL). MEDICAL AND PEDIATRIC ONCOLOGY 2001; 37:145-7. [PMID: 11496356 DOI: 10.1002/mpo.1186] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- I Müller
- University Children's Hospital, Department of Hematology and Oncology, Tübingen, Germany
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63
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Abstract
Hematopoietic stem cell transplantation is evolving into a treatment modality with expanding indications and volume and with excellent outcomes, although it carries significant risk for morbidity and mortality affecting most major organ systems and often requires ICU care. With continuing improvements in supportive care and specific therapy of complications following HCT including the open-lung strategy of mechanical ventilation, use of nitric oxide, less toxic myeloablative regimens, newer classes of antibiotics, and improved immunosuppression strategies, it is hoped that mortality in this setting will continue to decline in coming years.
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Affiliation(s)
- D A Horak
- Intensive Care Unit, Department of Respiratory Diseases, City of Hope National Medical Center, Duarte, California, USA
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64
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Abstract
Surgical evaluation of and therapy for the critically ill cancer patient continue to present significant challenges despite, or perhaps in part because of, an ongoing technologic refinement of therapeutic modalities within a modern ICU.
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Affiliation(s)
- S L Blair
- Department of General Oncologic Surgery, Division of Surgery, City of Hope National Medical Center, Duarte, California, USA
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65
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Abstract
Patients with disseminated herpes zoster may present with severe abdominal pain that results from visceral involvement of varicella-zoster-virus infection. In the absence of cutaneous eruptions of herpes zoster, visceral herpes zoster is extremely difficult to diagnose. This diagnostic difficulty has the potential to cause devastating delays in treatment. We report a case series of four patients with visceral herpes zoster in whom large concentrations of DNA from varicella zoster virus were detectable in blood by PCR before signs of infection appeared on the skin, thus enabling early diagnosis and treatment.
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66
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Affiliation(s)
- C Liatsos
- Liver Transplantation and Hepatobiliary Medicine, Royal Free Hospital, Hampstead, London, UK
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67
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Strasser SI, Shulman HM, Flowers ME, Reddy R, Margolis DA, Prumbaum M, Seropian SE, McDonald GB. Chronic graft-versus-host disease of the liver: presentation as an acute hepatitis. Hepatology 2000; 32:1265-71. [PMID: 11093733 DOI: 10.1053/jhep.2000.20067] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Chronic graft-versus-host disease (GVHD) of the liver usually presents as an indolent cholestatic disease in patients with skin, mouth, and eye involvement. We observed 14 patients in whom chronic GVHD of the liver presented with marked elevations of serum aminotransferases, clinically resembling acute viral hepatitis. Onset of liver dysfunction was at 294 days (range, 74-747 days) after allogeneic hematopoietic cell transplantation and coincided with a recent cessation or taper of immunosuppressive drugs. Median peak serum alanine transaminase (ALT) was 1,640 U/L (698-2,565 U/L), and median bilirubin was 12.3 mg/dL (0.9-55.9 mg/dL). All biopsies showed characteristic features of GVHD with damaged and degenerative small bile ducts. Other features included a marked lobular hepatitis, moderate to marked amounts of hepatocyte unrest, sinusoidal inflammation with perivenular necroinflammatory foci, and many acidophilic bodies scattered throughout the lobule. When high-dose immunosuppressive therapy was instituted soon after presentation, progressive improvement and eventual normalization of liver enzymes and bilirubin levels were observed. However, in cases in which the diagnosis was not made and therapy was delayed, a progressive cholestatic picture emerged with histologic evidence of loss of small bile ducts and portal fibrosis. We conclude that a distinct syndrome of chronic liver GVHD presenting as an acute hepatitis can be recognized in a patient at risk who is receiving no, or minimal, immunosuppressive medications. Liver biopsy is necessary to exclude viral causes of liver dysfunction and to confirm characteristic abnormalities of small bile ducts. Institution of high-dose immunosuppression can prevent progressive bile duct destruction and effect resolution of jaundice if given early.
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Affiliation(s)
- S I Strasser
- Gastroenterology/Hepatology, Pathology, and Long-Term Follow-Up Programs, Fred Hutchinson Cancer Research Center and the University of Washington School of Medicine, Seattle, WA 98109-1024, USA
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68
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Szabó F, Horvath N, Seimon S, Hughes T. Inappropriate antidiuretic hormone secretion, abdominal pain and disseminated varicella-zoster virus infection: an unusual triad in a patient 6 months post mini-allogeneic peripheral stem cell transplant for chronic myeloid leukemia. Bone Marrow Transplant 2000; 26:231-3. [PMID: 10918438 DOI: 10.1038/sj.bmt.1702486] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Severe abdominal pain followed by inappropriate antidiuretic hormone secretion (SIADH) preceding by several days the skin manifestation of varicella-zoster virus (VZV) infection in an immunocompromised patient is described. This is a rare presentation of a severe infection described previously only once in a chronic myeloid leukemia (CML) patient 5 months post allo-BMT during immunosuppressive treatment with cyclosporin A. This is the first case described in the setting of non-myeloablative preparation with fludarabine and melphalan and followed by donor leukocyte infusion (DLI) 2 and 4 months post allo-BMT. The influence of these factors on development of VZV virus infection is discussed. We also highlight the high incidence and high mortality in VZV infection in immunocompromised patients as well as the frequent atypical presentation.
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MESH Headings
- Abdominal Pain/etiology
- Abdominal Pain/virology
- Chickenpox/complications
- Chickenpox/etiology
- Chickenpox/virology
- Hematopoietic Stem Cell Transplantation/adverse effects
- Herpes Zoster/complications
- Herpes Zoster/etiology
- Herpes Zoster/virology
- Herpesvirus 3, Human
- Humans
- Immunocompromised Host
- Inappropriate ADH Syndrome/etiology
- Inappropriate ADH Syndrome/virology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/complications
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/virology
- Leukocyte Transfusion
- Male
- Middle Aged
- Transplantation, Homologous/adverse effects
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Affiliation(s)
- F Szabó
- Royal Adelaide Hospital, Department of Haematology and Bone Marrow Transplantation, Australia
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