Saudi Journal of Gastroenterology
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Year : 2008  |  Volume : 14  |  Issue : 2  |  Page : 102-103
Presumed acute pancreatitis during chickenpox infection in an otherwise healthy male


University of Bologna, C/O Infectious Diseases, S. Orsola Hospital, Via Massarenti 11, 40138 Bologna, Italy

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How to cite this article:
Manfredi R. Presumed acute pancreatitis during chickenpox infection in an otherwise healthy male. Saudi J Gastroenterol 2008;14:102-3

How to cite this URL:
Manfredi R. Presumed acute pancreatitis during chickenpox infection in an otherwise healthy male. Saudi J Gastroenterol [serial online] 2008 [cited 2020 Jul 7];14:102-3. Available from: http://www.saudijgastro.com/text.asp?2008/14/2/102/39631


Sir,

Kumar et al. [1] reported a rare case of fatal acute pancreatitis attributed to chickenpox infection in an otherwise healthy young man. This intriguing case report poses a series of challenging questions, and eventual authors' responses and clarifications are expected to add significantly to our limited knowledge in this field.

End-organ complications infrequently occur during primary, acute Varicella Zoster virus infection and may manifest via somewhat different pathogenetic pathways, including a direct viral damage or an indirect (usually immune-mediated) mechanism or a superinfection (usually bacterial in origin).

Among the few presumed predisposing conditions, the authors excluded the childhood [2] and the frankly immunocompromised patients, like those with AIDS, and those who had undergone bone marrow or solid-organ transplantation. On the other hand, it is well recognized that even severe chickenpox complications may occasionally occur in otherwise healthy people and especially subjects with unfavorable supporting conditions such as extreme old age, pregnancy, low-dose (including topical) corticosteroid therapy, and minor immunodeficient conditions.

Isolated cases of chickenpox-related acute pancreatitis have been anecdotally observed since nearly 50 years, especially in children, as per the global epidemiological records of chickenpox support, [2] but only in rare occurrences, the exact pathogenesis has been elucidated. This is because histopathological specimens are usually needed to distinguish acute viral damage due to an immune-mediated reaction from a superinfection or a multiorgan involvement. In most of these cases, unfortunately only necropsy studies clarified the pathogenesis and explained the single organ damage mechanisms.

An increased awareness of the pathogenesis of pancreatic damage may also have a significant impact in evaluating the role and timeliness of specific antiviral therapy, which is usually expected to add something only when started in the first 24-48 h of disease commencement [3],[4] and seems to reduce the incidence and/or the severity of organ complications, especially when a direct, viral-mediated damage is of concern.

With regard to the described patient, it could be very interesting to have some information on the predisposing factors: was the increased body mass index (obesity) associated with hyperlipidemia? and did it serve as a potential risk factor for pancreatitis? Were the prior serum amylase-lipase levels measured? Did it lead to any significant finding? And were there any concomitant medications?

Significantly, hepatic-biliary diseases were not evident at the time of occurrence of pancreatic complications, as assessed by biochemistry assays and abdominal imaging studies, although the more elevated serum amylase and lipase levels (907 and 562 U/L, respectively), did not reproduce those expected during hyperacute necrotizing hemorrhagic pancreatitis. Once again, histopathological and immunohistochemical data (eventually from the necropsy examination) are of interest for clarifying the etiopathogensis of pancreatic damage. They can also be used to correlate pancreatic damage with generalized multiorgan failure (seen more frequently in childhood and when an underlying immunodeficiency is of concern), which seems to have rapidly led to the death of the described patient. However, a direct viral damage cannot be excluded, since the authors suspected myocarditis and respiratory distress syndrome along with a probable liver involvement with an apparently inexplicable obstructive jaundice. [1] Also, for these complications, only histopathological studies and direct viral search by immunocytochemical assays, might clarify the pathogenesis and the exact role of Varicella Zoster virus infection in this series of not necessarily related complications. Among others, varicella vaccination has also been sporadically associated with the occurrence of acute pancreatitis. [5]

From a therapeutic point of view, some more clarity regarding antiviral therapy (time of start, dosage, and mode of administration) may be very interesting as well as useful, especially in the event that a direct (viral) pancreatic damage was suspected and possibly confirmed, to assess the role of treatment with acyclovir and its derivatives in such an hyperacute, life-threatening condition.

Finally, until the pathogenetic association has not been proven and the role of eventual co-factors has been carefully ruled out, the authors should refrain discussing "acute pancreatitis due to chickenpox." This last condition has been reported more frequently when compared with the only two adult otherwise healthy cases recorded by the authors, [6],[7],[8],[9],[10] although the clinical background was very different in each of the described cases.

In conclusion, the interesting case report presented by Kumar and colleagues may add even more to the knowledge of pathogenesis of viral tropism, the development of life-threatening multiorgan failure and the eventual role of specific antiviral therapy, should more details be added and discussed on the background of an updated literature review.

 
   References Top

1.Kumar S, Jain AP, Pandit AK. Acute pancreatitis: Rare complication of chicken pox in an immunocompetent host. Saudi J Gastroenterol 2007;13:130-40.  Back to cited text no. 1    
2.Schoenenberg H. Varicella virus as a cause of pancreatitis in childhood? Montatsschr Kinderheilkd 1961;109:236-8.  Back to cited text no. 2    
3.Manfredi R, Chiodo F; Acyclovir-chickenpox Italian Study Group. Acylovir therapy for immunocompetent children with chickenpox. Clin Infect Dis 1997;24:1261-2.  Back to cited text no. 3    
4.Manfredi R, Chiodo F, Titone L, Vierucci A, Catania S, Ghirardini G, et al. Chickenpox complications among immunocompetent hospitalized children in Italy. Pediatr Med Chir 1997;19:99-104.  Back to cited text no. 4    
5.Chan PW, Goh AY. Life threatening pancreatitis following varicella vaccination: Cause, association or co-incidence? Med J Malaysia 2000;55:527-8.  Back to cited text no. 5  [PUBMED]  
6.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. 6  [PUBMED]  
7.Pascual-Velasco F. Meningoencephalitis and pancreatitis caused by the Varicella virus, herpes zoster. Enferm Infecc Microbiol Clin 1996;14:396-7.  Back to cited text no. 7  [PUBMED]  
8.Nakane S, Honda H, Hamasaki S, Shirabe S, Nakamura T. A case of herpes zoster encephalitis with Ramsay-Hunt syndrome, herpes zoster generalisatus and acute pancreatitis. No To Shinkei 2000;52:43-7.  Back to cited text no. 8  [PUBMED]  
9.Malhi NS, Dutta U, Sathyanarayana H, Singh K. Acute pancreatitis: Presenting manifestation of varicella infection. Trop Gastroenterol 2004;25:82-3.  Back to cited text no. 9    
10.Kurtovic J, Webster GJ, Singh-Grewal I, Bullpitt P, Haindl W, Wakefield D, et al. Acalcolous cholecystitis, multifocal gastrointestinal infarction and pancreatitis resulting from Varicella-Zoster virus. Intern Med J 2005;35:69-70.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Roberto Manfredi
University of Bologna, C/O Infectious Diseases, S. Orsola Hospital, Via Massarenti 11, 40138 Bologna
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.39631

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