Letter to the Editor
Gastric involvement as an onset form of varicella zoster virus infection in a patient submitted to allogeneic hematopoietic stem cell transplant
Afectación gástrica como primera manifestación de infección por el virus varicela zóster en una paciente receptora de un trasplante alogénico de progenitores hematopoyéticos
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Visceral dissemination with gastric involvement is rare and is usually preceded by skin involvement, although in some cases it may be the first manifestation of infection, as occurred in the case discussed here.</p><p id="par0010" class="elsevierStylePara elsevierViewall">56-year-old woman diagnosed with acute myeloid leukaemia with t (11;17) (q23; p11.2) and <span class="elsevierStyleItalic">KMT2A</span> gene rearrangement. She received induction treatment with idarubicin and cytarabine, followed by a consolidation cycle with high-dose cytarabine. The patient had a complete cytological response (CCR) with undetectable residual disease (RD) and cytogenetic response, so an allogeneic haematopoietic stem cell transplant from an HLA-identical sibling with myeloablative conditioning (busulfan and cyclophosphamide) was performed. Graft-versus-host disease prophylaxis with cyclosporine and methotrexate was carried out, in addition to anti-infective prophylaxis with acyclovir, fluconazole, pentamidine, and levofloxacin. In the post-transplant reassessment bone marrow aspirate, a CCR was observed, with an RD of 0.05%, normal karyotype and complete donor chimerism.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Nine months after allogeneic transplantation, a bone-marrow relapse with RD of 14% was detected and t (11; 17) (q23; p11.2) was observed in nine metaphases. Mixed chimerism was detected (78% donor). Reinduction therapy with fludarabine, idarubicin, and cytarabine was administered. 33 days after the end of the induction, the patient presented with a 1-day history of oppressive central-thoracic pain unrelated to effort. The pain was accompanied by nausea and vomiting, without fever.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The electrocardiogram showed sinus rhythm without repolarisation abnormalities. The chest X-ray did not show consolidations in the lung parenchyma or signs of pleural or pericardial effusion. The blood count revealed pancytopenia. No alterations in the liver profile or elevation of pancreatic enzymes were observed. A troponin curve was performed, which was negative.</p><p id="par0025" class="elsevierStylePara elsevierViewall">NPO diet and proton pump inhibitors were prescribed, without improvement. A gastroscopy was performed in which multiple (15–20) ulcerations of 6–7 mm in diameter were observed in the gastric body, with a fibrinous background. Biopsies were taken and reported as a nonspecific acute inflammatory infiltrate. Immunohistochemical staining for cytomegalovirus (CMV) and herpes virus was negative. Serum polymerase chain reaction (PCR) was performed for herpesvirus and CMV, which were also negative. On the third day of admission, the patient presented with a generalised pruritic papulovesicular rash suggestive of chickenpox. Finally, PCR revealed the presence of VZV in the patient’s serum, skin lesions and gastric biopsy samples, and treatment with acyclovir was initiated, with progressive resolution of the symptoms.</p><p id="par0030" class="elsevierStylePara elsevierViewall">VZV infection is the most common viral infection in the late post-HSCT phase, and its frequency is between 17% and 50%.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is more common in allogeneic than in autologous HSCT.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It usually occurs after the first three to six months after transplantation.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This infection is typically cutaneous and is usually restricted to a dermatome, although it can be spread.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Visceral dissemination occurs in 10–15% of cases<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and in the vast majority occurs after the onset of skin lesions, although cases of visceral involvement without skin damage or skin lesions following visceral involvement,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> as in the case described, have been reported.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Gastric involvement due to VZV is rare, with high morbidity and mortality, ranging from 9% to 41% in immunosuppressed patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> When gastric involvement is not preceded by the characteristic skin lesions, early diagnosis can be complicated, as the clinical presentation may be non-specific (as in the case described, which presented with atypical chest pain). In this patient, two factors contributed to the VZV infection: immunosuppression due to allogeneic HSCT and due to the administration of fludarabine as part of the salvage therapy for leukaemia. In the immunocompromised patient, VZV infection should be considered in the differential diagnosis of abdominal pain with ulcer-like lesions on endoscopy, as delaying treatment can have serious consequences.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">Partly financed by the <span class="elsevierStyleGrantSponsor" id="gs0005">CERCA programme</span> (<span class="elsevierStyleGrantNumber" refid="gs0005">SGR 288 GRC</span>) Generalitat de Catalunya and by the <span class="elsevierStyleGrantSponsor" id="gs0010">La Caixa Foundation</span>.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Huguet M, Batlle M, Ribera J-M. Afectación gástrica como primera manifestación de infección por el virus varicela zóster en una paciente receptora de un trasplante alogénico de progenitores hematopoyéticos. Med Clin (Barc). 2021;157:257–258.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Varicella zoster-associated gastric ulcers, hepatitis and pancreatitis in an immunocompromised patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R.G. Remmerswaal" 1 => "A.C. de Vries" 2 => "D. 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