Case Presentation: A 75 year-old woman presented to the hospital with anasarca and worsening orthopnea for seven days. She was admitted for continued diuresis after failed outpatient management of acute-on-chronic heart failure exacerbation by her PCP. Recent imaging done in the outpatient setting had revealed new-onset ascites and a moderate-sized right-sided pleural effusion. The patient was hypoxic requiring nasal cannula and lung exam was notable for tachypnea and diminished breath sounds on the right with no wheezes or rales. She was tachycardic and in an irregular rhythm; there was symmetric pitting edema of the lower extremities. Her abdomen was distended but not tender. She had an erythematous rash with vesicles and bullae on the right T9 and T10 dermatomes; she was anicteric and afebrile. She was aggressively diuresed with continued IV therapy, and it was noted that she had been concomitantly started on valacyclovir by her PCP for the zoster rash first seen in her right upper quadrant, which was continued. She had near-complete resolution of her lower extremity edema after 48 hours, but her abdomen was more distended and her hypoxia had not improved; her vesicular lesions had crusted over, and a viral culture taken at admission was positive for varicella zoster virus (VZV). Cardiology felt the persistent ascites and pleural effusion were not explained by a cardiac etiology after echocardiogram was performed and other etiologies should be investigated. An initial paracentesis showed a low serum-ascites albumin gradient (SAAG) (0.6 g/dL) with high protein (4.1 g/dL) with only 72 white blood cells (WBCs), which was lymphocyte-predominant (70%); cytology was negative. Initial pleural fluid evaluation was transudative with a pH of 7.74 and a glucose of 127 mg/dL; cytology was negative. Abdomen and pelvis imaging was not suggestive of any hepatic, ovarian or pancreatic pathology, nor for any other notable abnormalities besides the large volume ascites, and urine studies were not suggestive of nephrotic syndrome. Upon further review with family, she had also had a history of latent tuberculosis; peritoneal and pleural fluid acid-fast bacilli culture and adenosine deaminase studies were negative. Ascites rapidly reaccumulated necessitating a second paracentesis: this revealed a lymphocyte-predominant peritonitis with WBC=13,000 (35% polymorphonuclear cells and 55% lymphocytes) and again a low SAAG and high protein; cytology was again negative. VZV PCR study from the peritoneal fluid was sent and came back positive. She was started on IV acyclovir. A subsequent pleural fluid analysis came back with a positive VZV PCR as well. She had documented clearance of disseminated infection in peritoneal and pleural fluid studies after 14 days of IV acyclovir therapy.
Discussion: Hospitalists commonly encounter patients presenting with edema and ascites, occasionally with an associated unilateral pleural effusion. The temporal onset associated with the zoster lesions in a dermatomal distribution in the right upper quadrant and posterior thorax led to investigation as to this being a possible etiology after literature review of zoster affecting the enteric nervous system (1) was undertaken following negative evaluation of more (and less) common etiologies.
Conclusions: VZV can manifest as peritonitis and should be considered in patients with zoster affecting abdominal dermatomes or those with other intraabdominal pathology that may be secondary to VZV reactivation in the enteric nervous system.