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CASE REPORT Table of Contents   
Year : 2007  |  Volume : 13  |  Issue : 3  |  Page : 138-140
Acute pancreatitis: Rare complication of chicken pox in an immunocompetent host


Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, Maharashatra, India

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Date of Submission28-Mar-2007
Date of Acceptance04-Jun-2007
 

   Abstract 

Chicken pox is a highly contagious infection, caused by the varicella zoster virus. Although generally a benign, self-limited disease, varicella may be associated with serious complications especially in adults. We present acute pancreatitis- a rare complication, in otherwise healthy patients suffering from chicken pox. The presence of pancreatitis in association with chickenpox in immunocompetent patients can influence the outcome of the latter. This interesting case will hopefully increase awareness about this complication and its fatality in chicken pox.

Keywords: Acute pancreatitis, chicken pox, complication

How to cite this article:
Kumar S, Jain A P, Pandit A K. Acute pancreatitis: Rare complication of chicken pox in an immunocompetent host. Saudi J Gastroenterol 2007;13:138-40

How to cite this URL:
Kumar S, Jain A P, Pandit A K. Acute pancreatitis: Rare complication of chicken pox in an immunocompetent host. Saudi J Gastroenterol [serial online] 2007 [cited 2019 Jul 23];13:138-40. Available from: http://www.saudijgastro.com/text.asp?2007/13/3/138/33467


Varicella (chickenpox) infection is a common and benign disease of childhood. The predominance of uncomplicated cases in children tends to overshadow the morbidity and mortality associated with severe cases and the resultant hospitalization. The risk of complication in the form of impaired motility is highest in people with compromised immune status, newborns and adults.


   Case Report Top


A 16 year-old male was admitted in the intensive care unit (ICU) of the Medicine department with complaints of abdominal pain, fever and eruptions over the body. The pain in the abdomen was of acute onset, severe, mainly in the upper central abdomen, continuous and radiating to the back. He had fever and eruptions all over the body (mainly present over the face, neck, chest, back, abdomen and genitals). Eruptions were gradually progressive and itching in nature. He also developed yellow discoloration in the eye. After 2-3 days of admission, the patient developed acute-onset breathlessness.

There was no history of vomiting, hemetemesis, malena or jaundice. There was no history of contact with any chicken pox patients. Neither did he have any addictions nor did his family have any significant illness. On examination, the patient was found to be obese with a body mass index (BMI) of 28. He was conscious, restless and febrile. His pulse was 140/minute, regular and his BP was 110/70 mm Hg. He had renal artery stenosis (RAS) and his respiratory rate was 36/minute, shallow and regular. He was pale and icteric.

Multiple small vesicular, maculopapular lesions with erythematous bases were present (pleomorphism) all over the face [Figure - 1], neck, shoulder, chest, abdomen and genitals. There was no involvement of oral mucosa, palms or soles. On abdominal examination, there was guarding and tenderness over the epigastrium and the umbilical region with free fluid in the peritoneal cavity. The liver was enlarged, soft and tender. Bowel sounds were sluggish. There was no splenomegaly or any other lump in the abdomen.

His hemoglobin was 10.5 gm/dl, total leukocyte counts 19,000 per cubic mm and his platelets were normal. He had conjugated hyperbilirubinemia (total bilurubin 5.7 gm/dl, conjugated 4.0 gm/dl) and liver enzymes were elevated (Aspartate aminotraferase of 97, Alanine aminotranferase of 144 and alkaline phosphatase of 945 IU/L). He was negative for Hepatitis B surface antigen. Serum lipase and serum amylase were 907 and 562 respectively. His chest film was normal on the first day but he developed acute respiratory distress syndrome (ARDS) on the following day. The X-ray of the abdomen was normal and cardiovascular system (CVS) and central nervous system (CNS) examinations were normal. Ultrasonography (USG) of the abdomen was normal, there was no biliary obstruction.

Computed tomography (CT) of the abdomen showed edematous pancreas with mild ascites, bilateral pleural effusion and generalized small bowel dilation. Ascitic fluid analysis was normal (Protein: 2.3, albumin: 1.9, adenosine deaminase (ADA) negative, total leukocyte count (TLC): 20, Lymphoid: 00). Cytology was negative for acid-fast bacilli (AFB) and there were no malignant cells. His Serum Ca 2+ was 0.78. Arterial blood gas analysis was normal except arterial oxyhaemaglobin saturation by pulse oximetry (SpO2), which was 78%. Moreover, he developed respiratory alkalosis with compensated metabolic acidosis on the following day. His varicella was confirmed by viral study of fluid from the rash by Tzanck test.

The patient received treatment in the form of nasogastric tube insertion and continuous aspiration, antibiotics (broad spectrum), acyclovir, intravenous fluid, proton pump inhibitors. Central insertion was done and vitals were monitored along with the general supportive care. Sinus tachycardia was persistent and the possibility of viral myocarditis was considered.

The patient was put on invasive ventilation to monitor his ARDS. However, the patient subsequently deteriorated and expired.


   Discussion Top


Chicken pox is typically a benign but highly contagious, self-limiting disease, which is common in children. However, the epidemiology of varicella seems to differ in tropical climates, seasonality being described less clearly and varicella found commonly among adults in these areas. [1] This higher adult susceptibility may result from a lack of exposure to varicella zoster virus (VZV) during childhood due to rural living conditions in the tropics where VZV circulates poorly [2] or due to high ambient temperature of the tropics, that inactivates VZV in cutaneous lesions, thereby lessening its transmission potential. [3]

The risk of complication is highest in people with compromised immune status and in newborns and adults. Varicella pneumonia is the most common complication in adults. Estimates of its incidence vary between 16-25% in most reports. [4] Encephalitis is the second most common complication in adults, occurring in 0.1-0.2% of infected persons and causing a mortality rate between 5-20%. [5] Other neurologic manifestations include meningitis, transverse myelitis and cerebellar ataxia. [6] Subclinical hepatitis and elevated liver enzymes are more common in adults and are frequently associated with pneumonia. [7] Acute myocarditis, [8] acute pancreatitis [9] and acute liver failure [10] are among the rare complications.

There may be liver complications like transient hepatitis, which does not usually cause symptoms and resolves on its own. In this patient of varicella, The complications presented in our patient-acute pancreatitis and jaundice, were rare. ARDS was part of the acute pancreatitis complication. The cause of obstructive jaundice in this case was inexplicable; but we did consider the possibilities of either complication of varicella or pancreatitis.

We had ruled out any obstructive pathology by abdominal sonography and CT. In addition, we had conducted an extensive search using PUBMED, which indicated there were reports of complications such as pancreatitis in chicken pox, although all were in infants, children and immunocompromised patients. Only two case reports were found in literature for adults, but in one case, the patient was receiving corticosteroid therapy for the preceding one month after the evacuation of a traumatic subdural hematoma. [11],[12]

 
   References Top

1.Venkitaraman AR, John IJ. The epidemiology of varicella in staff and students of a hospital in torpics. Int J Epidemiol 1984;13:502-5.  Back to cited text no. 1    
2.Mandal BK, Mukherjee P, Murphy C, Mukherjee R, Naik T. Adult susceptibility is a rural phenomenon due to lack of previous exposure. J infect Dis 1998;178:S52-4.  Back to cited text no. 2    
3.Garnett GP, Cox MJ, Bundy DA, Didier JM, St Catharine J. The age of infection with varicella-zoster virus in St Lucia, West Indies. Epidemiol Infect 1993;110:361-72.  Back to cited text no. 3  [PUBMED]  
4.Hockberger RS, Rothstein RJ. Varicella pneumonia in adults spectrum of disease. Ann Emerg Med 1986;15:931-4.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Richard J. Whitley varicella zoster virus. In : Mandel, Douglas et al. text book of principle and practice of infectious disease. 5 th ed. Churchil Living Stone Co: 2000. p. 1580-5.  Back to cited text no. 5    
6.Bourazz A, Ouhabi H, Boutaleb N, Rouimi A, N'Diaye M, Mosseddaq R. Neurologic complications of varicella in adults. Rev Neurol (Paris) 1998;154:412-4.  Back to cited text no. 6    
7.Bovill B, Bannister B. Review of 26 years' hospital admissions for chickenpox in North London. J Infect 1998;36:17-23.  Back to cited text no. 7    
8.Noriega Peiró F, Costas Alonso MI, Vilar Freire M, Fernαndez Alvarez R, Martνn Joven A, Lago A. Acute myocarditis caused by varicella virus. Rev Esp Cardiol 1998;51:677-9.  Back to cited text no. 8    
9.Maillot C, Riachi G, Francois A, Ducrotte P, Lerebours E, Hemet J, et al . Digestive manifestations in an immunocompetent adult with varicella. Am J Gasteroenterol 1997;92:1361-3.  Back to cited text no. 9    
10.Dits H, Frans E, Wilmer A, Van Ranst M, Fevery J, Bobbaers H. Varicella zoster virus infection associated with acute liver failure. Clin Infect Dis 1998;27:209-10.  Back to cited text no. 10  [PUBMED]  
11.Malhi NS, Dutta U, Sathyanarayana G, Singh K. Acute pancreatitis: Presenting manifestation of varicella infection. Trop Gastroenterol 2004;25:82-3.  Back to cited text no. 11  [PUBMED]  
12.Kirschner S, Raufman JP. Varicella pancreatitis complicated by pancreatic pseudocyst and duodenal obstruction. Dig Dis Sci 1988;33:1192-5.  Back to cited text no. 12  [PUBMED]  

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Correspondence Address:
Sunil Kumar
Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra - 442 102
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.33467

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