Disseminated Chickenpox with Multi-organ Failure in an Immunocompetent Adult. A Case Report and Literature Review

Disseminated Chickenpox with Multi-organ Failure in an Immunocompetent Adult. 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A Case Report and Literature Review Jaweria Akram, Abdul Qadir, Hadeel Alfar, Theresa Paul, Mamunul Islam, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5710632/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 May, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Disseminated varicella infection in adults, particularly those with mild immunosuppression, can lead to severe complications and life-threatening outcomes. Early diagnosis and intervention are critical yet challenging due to atypical presentations. Case presentation: A previously healthy 26-year-old male presented with severe epigastric and right upper quadrant abdominal pain radiating to the back, nausea, loss of appetite, and constipation. He had been taking oral prednisolone 5mg daily for 2 weeks prior to symptom onset. Initial evaluation showed mild liver enzyme elevation but normal imaging studies. Within two days, he developed widespread vesicular lesions consistent with varicella, rapidly progressing to fulminant hepatic failure, disseminated intravascular coagulation (DIC), acute renal failure, and acute respiratory distress syndrome (ARDS). Despite intensive management including antiviral therapy, antibiotics, supportive transfusions, and mechanical ventilation, the patient unfortunately passed away due to multi-organ failure. Conclusion: This case emphasizes the importance of early suspicion and diagnosis of varicella infection in adults presenting with atypical symptoms, even low-dose steroid therapy may cause sufficient immunosuppression to predispose individuals to disseminated viral infections. Timely intervention can significantly influence patient outcomes. Coagulopathy disseminated chickenpox infection fulminant hepatitis Varicella zoster in immune-competent adults Figures Figure 1 Figure 2 Introduction Varicella-zoster virus (VZV) is one of eight herpesviruses known to cause human infection. VZV infection causes two clinically distinct forms of disease: varicella (chickenpox) and herpes zoster (shingles). Primary VZV infection results in the diffuse vesicular rash of varicella, or chickenpox. Endogenous reactivation of latent VZV typically results in a localized skin infection known as herpes zoster, or shingles. Primary varicella infection in children is generally a mild disease compared to more severe presentations in adults or immunocompromised patients of any age. However, in adults, particularly those immunocompromised or even mildly immunosuppressed, varicella infection can manifest as severe, disseminated disease leading to life-threatening complications. Prompt recognition of atypical presentations is critical in improving outcomes. Here, we describe an unusual and severe case of disseminated varicella infection complicated by multi-organ failure in a previously healthy young adult, highlighting the importance of clinical vigilance and early intervention. Case Presentation A previously healthy 26-year-old male presented to the emergency department (ED) with a 2-day history of severe, colicky epigastric and right upper quadrant (RUQ) abdominal pain radiating to the back, rated 9/10 in severity, accompanied by nausea, loss of appetite, and constipation. He was taking prednisolone 5mg daily, ibuprofen 400mg three times daily, and gabapentin 200mg daily for two weeks, prescribed by a primary care physician for presumed neuropathic back pain, which was described as burning in character and radiating to the lower limbs. He was not evaluated in a hospital setting for his back pain. The patient denied fever, chills, or jaundice. He reported contact with a co-worker who was diagnosed with chickenpox four days prior to symptom onset. He received all childhood immunization, but he was not immunized against chicken pox. On initial assessment, the patient was alert and oriented, with stable vital signs (BP: 118/72 mmHg, HR: 72 bpm, RR: 19 breaths/min, Temp: 36.8°C, SpO2: 100%). Examination revealed significant tenderness localized to the epigastric region without guarding or rebound tenderness. Laboratory results at presentation were largely within normal limits except mildly elevated liver enzymes (ALT 46 U/L, AST 54 U/L) (Table 1). Initial imaging, including ultrasound and contrast-enhanced CT of the abdomen, was unremarkable, ruling out acute cholecystitis, biliary pathology, and intestinal ischemia. Initial chest X-ray was also normal (Figure 1). Pantoprazole 40mg IV once daily was started for stress ulcer prophylaxis. Despite analgesic therapy including paracetamol (1g IV), morphine (10mg/ml), and fentanyl (40 mcg), abdominal pain persisted and worsened, eventually accompanied by severe back pain. The patient received six grams of paracetamol over 2 days (three doses/day). While this dose is within the upper therapeutic limit, it may contribute to liver injury in a compromised liver. On day 2 of admission, the patient developed widespread vesicular eruptions beginning on his forehead and spreading caudally, sparing the palms and soles, consistent with varicella infection. Concomitantly, his clinical condition rapidly deteriorated. Follow-up laboratory tests showed severe hepatic dysfunction (ALT 1437 U/L, AST >1000 U/L), profound coagulopathy (INR 3.5, markedly prolonged PT/APTT, fibrinogen <0.3 gm/L), leukocytosis (WBC 23.6 ×10³/µL), and elevated inflammatory markers (CRP 15.0 mg/L, Procalcitonin 0.12 ng/mL). Varicella polymerase chain reaction (PCR) from vesicular lesions was positive, confirming disseminated varicella zoster infection. His condition further complicated by hemorrhagic transformation of vesicles, subconjunctival hemorrhage, active bleeding from intravenous sites, and progressive encephalopathy. The patient developed altered mental status with decreased Glasgow Coma Score (GCS), prompting evaluation for hepatic encephalopathy. As a result, investigations were undertaken to exclude other potential causes of acute liver failure, including viral, autoimmune, and drug-induced etiologies. Empiric intravenous acyclovir therapy, broad-spectrum antibiotics (piperacillin-tazobactam), supportive transfusions (fresh frozen plasma (FFP), cryoprecipitate), and intensive care management were promptly initiated. The patient met clinical and laboratory criteria for disseminated intravascular coagulation (DIC), including prolonged PT/aPTT, elevated INR (4.9), low fibrinogen (<0.3 g/L), and severe thrombocytopenia (platelets: 23 x10^9/L), along with diffuse bleeding from cannula sites, gums, and conjunctiva. Despite maximal supportive interventions including mechanical ventilation, renal replacement therapy for acute renal failure, and vasopressor support for refractory shock, the patient's condition progressed rapidly to multiorgan failure, DIC, and acute respiratory distress syndrome (ARDS) (Figure 2). The patient unfortunately passed away due to cardiac arrest and multi-organ failure on the sixth day of hospitalization. This case underscores the critical importance of early recognition of atypical presentations of varicella in adults, particularly when complicated by even low-dose steroid-induced immunosuppression, to prevent catastrophic outcomes. Table 1: Hematology: DAY1 DAY3 DAY4 WBC 9.5 11-->28 6.4 Hgb 15.4 10.9 3.6 hct 44.9 46.6 3.6 MCV/MCH Normal Normal Normal Platelets 220 131 23 Absolute reticulocyte count - - 0.3 Reticulocyte index - - O.11 Coagulation profile: DAY1 DAY3 DAY4 PT (sec) - 40.2 26.9 INR - 3.5-->4.9 2.7 D-dimer - Unable to analyze by the machine Unable to analyze by the machine Fibrinogen (gm/l) - 180 Chemistry: Day1 Day2 Day3 Urea (mmol/l) 2.5 5 4.3 Creatinine (umol/l) 47 171 192 Na (mmol/l) 142 128 138 K (mmol/l) 3.5 4.8 5 Cl (mmol/l) 104 90 91 Hco3 (mmol/l) 26 25 13 Phosphorous (mmol/l( - 1.9 2.5 ALT (U/L) 46 1,437-->2,020 1,239 AST (U/L) 54 1,000-->6,045 2,651 CK (mmol/l) - 2,821 Ammonia (umol/l) - - 66 Lipase (U/L) 17 - - Ceruloplasmin (mg/dl) - 10 - CRP (mg/l) 1 15 3.5 Lactic acid (mmol/l) 1.8 2.4 1.7 Procalcitonin (mg/l) - 0.12 10 Endocrinology: DAY1 DAY3 DAY4 Ferritin (ug/l) - - 64,653 Toxicology: DAY1 DAY3 DAY4 Acetaminophen level (umol/l) - 11.4 - Autoimmune disease: DAY1 DAY3 DAY4 ASM Ab - negative - ALKM - negative - ANA CTD int - negative - C3 (mg/l) - 88.9 72 C4 (mg/l) - 14.3 14.1 Serology: DAY1 DAY3 DAY4 Varicella Zoster - IgM / lgG negative PCR positive IgM /IgG negative PCR positive Measles - IgM negative IgG positive - HCV - IgM/IgG/PCR negative - HBV - IgM/IgG/PCR negative - HIV - IgM/IgG/PCR negative - EBV (IU/L) - PCR positive; 1,455 - Abbreviations: WBC – White Blood Cell count, Hgb – Hemoglobin, Hct – Hematocrit, MCV/MCH – Mean Corpuscular Volume / Mean Corpuscular Hemoglobin, PT sec – Prothrombin Time (in seconds), INR – International Normalized Ratio, aPTT – Activated Partial Thromboplastin Time, Na – Sodium, K – Potassium, Cl – Chloride, HCO₃ – Bicarbonate, ALT – Alanine Aminotransferase, AST – Aspartate Aminotransferase, CK – Creatine Kinase, CRP – C-Reactive Protein, ASM Ab – Anti-Smooth Muscle Antibody, ALKM – Anti-Liver-Kidney Microsomal Antibody, ANA – Antinuclear Antibodies, HCV – Hepatitis C Virus, HBV – Hepatitis B Virus, HIV – Human Immunodeficiency Virus, EBV – Epstein–Barr Virus PCR for varicella from skin swab was positive Discussion Diagnosis of VZV is often clinical, based on characteristic skin lesions of vesicular exanthem and associated systemic symptoms. However, diagnosis may be challenging in cases presenting with atypical features such as isolated abdominal or back pain, which can precede the rash. Such prodromal symptoms have been documented in children ( 1 ) and immunocompromised individuals, and in a limited number of reports involving immunocompetent adults as well ( 2 – 11 ). These manifestations are thought to result from VZV-related myeloradiculopathy, a recognized neurological complication of the infection ( 12 ). The diagnosis of fulminant hepatitis was based on established clinical criteria—acute onset liver dysfunction with an INR > 1.5 and hepatic encephalopathy in a patient without preexisting liver disease. Definitive diagnosis of VZV can be made using PCR for viral DNA, serology, or direct fluorescent antibody testing. Tzanck smear may show multinucleated giant cells with intranuclear inclusions. Our case demonstrates the diagnostic challenge in recognizing disseminated varicella in its early phase, where initial symptoms mimic non-infectious gastrointestinal or neurologic pathology. Despite early hospital presentation, diagnosis was delayed due to absence of rash and normal imaging. Once the vesicular rash appeared, the disease course progressed rapidly, leading to multiorgan failure. The benefits in this case included early initiation of empirical therpy, with acyclovir, supportive ICU care, and transfusions. However, limitations included delayed consideration of VZV in differential diagnoses, and the use of immunosuppressant (prednisolone 5mg/day) for nonspecific back pain, potentially exacerbating the viral dissemination. The differential diagnosis of VZV infection includes smallpox, coxsackievirus, echovirus, rickettsia pox, and atypical measles. Other important considerations are meningococcemia, disseminated gonococcal infection, bullous vasculitis, infectious endocarditis, acute generalized exanthematous pustulosis, pustular psoriasis, and Mucha-Habermann disease. Disseminated varicella can lead to serious complications, including pneumonia, encephalitis, hepatitis, and hemorrhagic manifestations. Individuals with hematologic or solid organ malignancies, diabetes mellitus, or inherited thrombophilias (such as protein C and S deficiencies) are considered at higher risk for severe disease ( 13 – 14 ). Complications are significantly more common in adults than in children ( 15 ). Notably, up to 90% of varicella pneumonia cases occur in adults. Less frequent but severe complications include myocarditis, gangrene, retinitis, glomerulonephritis, Reye syndrome, Guillain-Barré syndrome (GBS), acute cerebellar ataxia, and disseminated intravascular coagulation (DIC). Patients should be placed under droplet and contact precautions until all vesicular lesions have crusted. Antiviral therapy with intravenous acyclovir should be initiated as early as possible, ideally within four days of rash onset, to reduce morbidity and mortality ( 16 ). We reviewed the literature for reported cases of disseminated varicella-zoster virus (VZV) infection in immunocompetent adults presenting with fulminant hepatic failure and/or abdominal pain as a primary symptom. Our search, limited to English-language publications, identified approximately 10 individual case reports; no case series or systematic reviews were found (Table 2 ). Most patients were reported to be previously healthy without known immunosuppression. However, two patients had comorbidities potentially impacting immune response: one had hepatitis B (case 6), and another had immune thrombocytopenic purpura post-splenectomy (case 10). No cases involved known malignancy, HIV, or long-term immunosuppressive therapy. We performed a structured literature review using PubMed, Scopus, and Google Scholar databases. All the patients had abdominal pain with or without fever at time of presentation. Abdominal and back pain, though non-specific, have been documented in varicella cases as potential early manifestations. These symptoms are hypothesized to result from VZV-induced myeloradiculopathy or visceral neuropathy. The patient’s right upper quadrant pain could also be attributed to hepatic inflammation and capsular distension during the early stages of viral hepatitis. Although drug-induced liver injury cannot be entirely excluded, low acetaminophen levels (11.4 µmol/L) and lack of temporal correlation argue against it as the primary cause. All patients received treatment with acyclovir. Hepatic dysfunction was observed in every case, with six patients progressing to fulminant hepatitis. The diagnosis of fulminant hepatitis was based on established clinical criteria—acute onset liver dysfunction with an INR > 1.5 and hepatic encephalopathy in a patient without preexisting liver disease ( 6 ). Additional complications included DIC, rhabdomyolysis, encephalitis, nephritis, thrombocytopenia, refractory distributive shock, and multiorgan failure involving both respiratory and renal systems. Despite aggressive treatment, five patients died. Table 2 No Patient characteristics Co-morbidities Presentation Treatment Outcome 1 ( 2 ) 22 years old female Positive sick contact No comorbidities, immunocompetent Back pain radiating to back, fever, then rash appeared Acyclovir and supportive treatment Hepatitis, pneumonia, DIC Recovered 2 ( 3 ) 60 years old female Positive sick contact No comorbidities; immunocompetent Epigastric pain, vomiting, fever, rash appeared two days later Acyclovir and supportive treatment Hepatic failure, DIC, pneumonia, multiorgan failure Passed away 3 ( 4 ) 32 years old Positive sick contact No comorbidities; immunocompetent abdominal pain, fever, vomiting, rash Acyclovir and supportive treatment Varicella hepatitis, DIC, nephritis Passed away 4 ( 5 ) 26 years old female Positive sick contact No comorbidities; immunocompetent Epigastric pain, fever, rash Acyclovir and supportive treatment Hepatic failure, DIC. Passed away Autopsy proven multiorgan involvement 5 ( 6 ) 20 years old male known asthmatic (Not on steroids) Fever, abdominal and back pain, rash Acyclovir and supportive treatment Hepatic dysfunction, multiorgan failure, Passed away 6 ( 7 ) 40 years old male Positive sick contact Hepatitis B (not on medications) Rash, fever, abdominal pain, jaundice Acyclovir and supportive treatment Hepatic failure, renal failure, DIC, passed away due to multi organ failure 7 ( 8 ) 18 years old male No comorbidities; immunocompetent Abdominal pain, fever, active bleeding from nose and gums, blood in urine and stool Later developed restlessness and agitation Acyclovir and supportive treatment Hepatitis dysfunction, DIC, encephalitis, septicemia Recovered 8 ( 9 ) 23 years old male No comorbidities; immunocompetent Epigastric pain, later developed rash Acyclovir and supportive treatment ARDS, rhabdomyolysis, acute hepatitis, DIC Recovered 9 ( 10 ) 28 years old male No comorbidities; immunocompetent Rash, fever Acyclovir and supportive treatment Hepatitis, pneumonia, rhabdomyolysis, DIC 10 ( 11 ) 36 years female Immune thrombocytopenia (ITP) post splenectomy abdominal pain, nausea, fever, sore throat, vesicular rash Acyclovir and supportive treatment Hepatitis Recovered Our case closely parallels those previously reported, with an initial presentation of acute abdominal pain in the absence of rash. The rash appeared later, coinciding with worsening liver function, and ultimately progressed to fulminant hepatic failure with multiorgan involvement. Our patient had a history of taking low-dose prednisolone (5 mg daily) for 2 weeks prior to the onset of symptoms. Previous reports of fulminant varicella have described similar outcomes in patients who were taking low-dose steroids, although not all studies provided exact dosages ( 15 , 16 ). Conclusion Although chickenpox is uncommon in adults, it often follows a more severe course with potentially life-threatening complications. This case highlights the importance of considering VZV infection in adults presenting with atypical symptoms such as isolated abdominal or back pain, especially when no clear surgical cause is found. Clinicians must maintain a high index of suspicion for varicella in adults with non-specific prodromal symptoms, as misdiagnosis and delay in treatment can be fatal. Even low-dose steroid therapy may cause sufficient immunosuppression to predispose individuals to disseminated viral infections, including fulminant varicella. This case highlights the importance of considering such risks when prescribing corticosteroids. Declarations Ethics approval and Consent to participate: The Medical Research Center at Hamad Medical Corporation in Qatar has granted approval for the publication of this case report under the reference number MRC-04-19-132. Consent for Publication: Written informed consent for publication of the details of this medical case and any accompanying images was obtained from the next of kin, as the patient is deceased. Availability of data and materials: The data that supports the finding of this case report are contained within the article. Additional information is available from the corresponding author upon reasonable request and with the approval of relevant ethics committee. Competing Interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding: This case report was not funded. Author Contributions: Conceptualization: Jaweria Akram, Abdul Qadir Data Curation: Jaweria Akram, Abdul Qadir Writing - Original Draft: Jaweria Akram, Abdul Qadir, Hadeel Alfar Writing – Review and Editing: Jaweria Akram, Abdul Qadir, Hadeel Alfar, Theresa Paul, Mamunul Islam, Ali Rahil All authors read and approved the final manuscript Acknowledgements: We would like to acknowledge the Qatar National Library (QNL) for open access publication funding of this article. References Milone G, Di Raimondo F, Russo M, Cacciola E Jr, Giustolisi R. Unusual onset of severe varicella in adult immunocompromised patients. Ann Hematol. 1992;64(3):155–6. Ahamed SP, Balkhair A, Krishnan R. Fulminant varicella zoster infection with multiorgan involvement: a case report. Sultan Qaboos Univ Med J. 2008;8(3):339–43. De Vas Goonewardane APN, Sanjeewa NHR, Perera T, Weerakoon RR. Malignant chickenpox with coagulopathy in a healthy adult female;a case report and review of literature. Galle Med J. 2015;20(2):46–7. Kaur H, et al. Coagulopathy secondary to chicken pox: a case report. Int J Adv Med. 2017;4(6):1706–8. Daren R, Anderson J, Schwartz NJ, Hunter, et al. Varicella Hepatitis: A Fatal Case in a Previously Healthy, Immunocompetent AdultReport of a Case, Autopsy, and Review of the Literature. Arch Intern Med. 1994;154(18):2101–6. Carl V, Vartin, Dits H, Frans E, Wilmer A, et al. Varicella zoster infection associated with acute liver failure. Clin Infect Dis. 1998;27:209–10. Bhatti MA, Manglani CB, Khan MA. Fatal case of chickenpox in an Adult: A case report. J Pak Med Assoc. 2004;54(2). Mostofa Kamal Chowdhury, Siddique AAA, Haque M, Ali S, Biswas S et al. Prodip Kumar Biswas,. Life Threatening Complications of Chicken Pox in a Young Adult. J MEDICINE. 2014;15:55–56. Soshoku LEE, Nobuyuki ITO, Tomoko INAGAKI, Tatsuya OKAJIMA, Atsushi MURAMATSU, Yoshiyuki ITO, Manabu DOJO, et al. Fulminant Varicella Infection Complicated with Acute Respiratory Distress Syndrome, and Disseminated Intravascular Coagulation in an Immunocompetent Young Adult. Intern Med. 2004;43(12):1205–09. Brabant AB-DS, Chatellier D, Bourgoin A, Robert R, Ruckes T, et al. Disseminated Varicella With Multiorgan Failure in an Immunocompetent Adult. J Med Virol. 2009;81:747–9. Borum ML, Zimmerman, Hyman J. Hepatitis Associated with Varicella Infection in an Immunocompetent Adult J. Clin. Gastroenterol. 1996;23(2):165. Arvin A, Ageing. Immunity and Varicella zoster viruses. N Eng J Med. 2005;352:2266–7. Vinzio S, Lioure B, Goichot B. Varicella in immunocompromised patients. Lancet. 2006;368(9554):2208. Nguyen P, Reynaud J, Pouzol P, et al. Varicella and thrombotic complications associated with transient protein C and protein S deficiencies in children. Eur J Pediatr. 1994;153(9):646–9. Almuneef M, Memish ZA, Balkhy HH, Alotaibi B, Helmy M. Chickenpox complications in Saudi Arabia: Is it time for routine varicella vaccination? Int J Infect Dis. 2006;10(2):156–61. Peterslund NA. Management of varicella zoster infections in immunocompetent hosts. Am J Med. 1988;85(2A):74–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 May, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Accepted 21 Apr, 2025 Reviews received at journal 19 Apr, 2025 Reviews received at journal 16 Apr, 2025 Reviews received at journal 09 Apr, 2025 Reviewers agreed at journal 09 Apr, 2025 Reviewers agreed at journal 05 Apr, 2025 Reviewers agreed at journal 03 Apr, 2025 Reviewers invited by journal 03 Apr, 2025 Submission checks completed at journal 03 Apr, 2025 First submitted to journal 02 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5710632","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":438920182,"identity":"4515a1e2-a094-45be-a3a1-564d5cdfb3d8","order_by":0,"name":"Jaweria Akram","email":"","orcid":"","institution":"Hamad Medical Corporation, HGH","correspondingAuthor":false,"prefix":"","firstName":"Jaweria","middleName":"","lastName":"Akram","suffix":""},{"id":438920183,"identity":"41239c38-2e0c-44fd-bf23-455bfce86b14","order_by":1,"name":"Abdul Qadir","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYBACNvkGBgnGBoYEfgkwlwgt/BIHIFokZxCrRXJGAkSLwQ1itRjcOPzw5s8ddnnGt5ufbvhRxiDb30BIy/02Y2veM8nFZneOmd3sOcdgPOMAQVsOmEkztjEnbruRYHaDt40hsYGQFvsb6d8kf7bVJ26ekf7t5l+glvmEbckxk+BtO5y4QSLH7DbIlg2EtZwptuZtO54440ZO2W2ZcxLGGwlqud++8ebPturE/hnp226+KbORnUdICzoAxRGpgAwto2AUjIJRMNwBAHg0T3zjeXcoAAAAAElFTkSuQmCC","orcid":"","institution":"Hamad Medical Corporation, HGH","correspondingAuthor":true,"prefix":"","firstName":"Abdul","middleName":"","lastName":"Qadir","suffix":""},{"id":438920184,"identity":"0dda9622-2a8b-480b-9c1a-c400fad086b3","order_by":2,"name":"Hadeel Alfar","email":"","orcid":"","institution":"Cook County Health","correspondingAuthor":false,"prefix":"","firstName":"Hadeel","middleName":"","lastName":"Alfar","suffix":""},{"id":438920185,"identity":"0d36ce03-a921-471d-ab50-60a557204169","order_by":3,"name":"Theresa Paul","email":"","orcid":"","institution":"Hamad Medical Corporation, HGH","correspondingAuthor":false,"prefix":"","firstName":"Theresa","middleName":"","lastName":"Paul","suffix":""},{"id":438920186,"identity":"9465f9e8-7e70-4ab3-94b2-0c734852dfb1","order_by":4,"name":"Mamunul Islam","email":"","orcid":"","institution":"Hamad Medical Corporation","correspondingAuthor":false,"prefix":"","firstName":"Mamunul","middleName":"","lastName":"Islam","suffix":""},{"id":438920187,"identity":"a0b8f268-d650-42c7-a384-53eceafcf86c","order_by":5,"name":"Ali Rahil","email":"","orcid":"","institution":"Hamad Medical Corporation, HGH","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Rahil","suffix":""}],"badges":[],"createdAt":"2024-12-25 10:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5710632/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5710632/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-025-11015-0","type":"published","date":"2025-05-20T15:58:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80062718,"identity":"ebb0517c-80d2-4405-89d3-23fc78efcb6b","added_by":"auto","created_at":"2025-04-07 12:39:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":59766,"visible":true,"origin":"","legend":"\u003cp\u003eDay 1\u003c/p\u003e\n\u003cp\u003eChest XR: AP view showing bilateral diffuse alveolar opacities with increased reticular shadows suggestive of ARDS, normal cardiac shadow, NGT and central line are in situ.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5710632/v1/f5c21c39db46e5d0329ff794.jpg"},{"id":80062717,"identity":"5e13ba00-238a-4fdd-ac20-7c684f5ded2f","added_by":"auto","created_at":"2025-04-07 12:39:52","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":56780,"visible":true,"origin":"","legend":"\u003cp\u003eDay 3\u003c/p\u003e\n\u003cp\u003eChest XR: AP view showing bilateral diffuse alveolar opacities with increased reticular shadows suggestive of ARDS, normal cardiac shadow, NGT and central line are in situ.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5710632/v1/5945dd1021e04a1f6c9e7ac8.jpg"},{"id":83460079,"identity":"57892852-18a2-4e59-8d51-54698b3d009e","added_by":"auto","created_at":"2025-05-26 16:10:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":816666,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5710632/v1/82874ba3-2b6b-47b5-bcee-b19c988925ad.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Disseminated Chickenpox with Multi-organ Failure in an Immunocompetent Adult. A Case Report and Literature Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVaricella-zoster virus (VZV) is one of eight herpesviruses known to cause human infection. VZV infection causes two clinically distinct forms of disease: varicella (chickenpox) and herpes zoster (shingles). Primary VZV infection results in the diffuse vesicular rash of varicella, or chickenpox. Endogenous reactivation of latent VZV typically results in a localized skin infection known as herpes zoster, or shingles.\u003c/p\u003e \u003cp\u003ePrimary varicella infection in children is generally a mild disease compared to more severe presentations in adults or immunocompromised patients of any age. However, in adults, particularly those immunocompromised or even mildly immunosuppressed, varicella infection can manifest as severe, disseminated disease leading to life-threatening complications. Prompt recognition of atypical presentations is critical in improving outcomes. Here, we describe an unusual and severe case of disseminated varicella infection complicated by multi-organ failure in a previously healthy young adult, highlighting the importance of clinical vigilance and early intervention.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA previously healthy 26-year-old male presented to the emergency department (ED) with a 2-day history of severe, colicky epigastric and right upper quadrant (RUQ) abdominal pain radiating to the back, rated 9/10 in severity, accompanied by nausea, loss of appetite, and constipation. He was taking prednisolone 5mg daily, ibuprofen 400mg three times daily, and gabapentin 200mg daily for two weeks, prescribed by a primary care physician for presumed neuropathic back pain, which was described as burning in character and radiating to the lower limbs. He was not evaluated in a hospital setting for his back pain. The patient denied fever, chills, or jaundice. He reported contact with a co-worker who was diagnosed with chickenpox four days prior to symptom onset. He received all childhood immunization, but he was not immunized against chicken pox.\u003c/p\u003e\n\u003cp\u003eOn initial assessment, the patient was alert and oriented, with stable vital signs (BP: 118/72 mmHg, HR: 72 bpm, RR: 19 breaths/min, Temp: 36.8\u0026deg;C, SpO2: 100%). Examination revealed significant tenderness localized to the epigastric region without guarding or rebound tenderness. Laboratory results at presentation were largely within normal limits except mildly elevated liver enzymes (ALT 46 U/L, AST 54 U/L) (Table 1).\u003c/p\u003e\n\u003cp\u003eInitial imaging, including ultrasound and contrast-enhanced CT of the abdomen, was unremarkable, ruling out acute cholecystitis, biliary pathology, and intestinal ischemia. Initial chest X-ray was also normal (Figure 1). Pantoprazole 40mg IV once daily was started for stress ulcer prophylaxis. Despite analgesic therapy including paracetamol (1g IV), morphine (10mg/ml), and fentanyl (40 mcg), abdominal pain persisted and worsened, eventually accompanied by severe back pain. The patient received six grams of paracetamol over 2 days (three doses/day). While this dose is within the upper therapeutic limit, it may contribute to liver injury in a compromised liver.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn day 2 of admission, the patient developed widespread vesicular eruptions beginning on his forehead and spreading caudally, sparing the palms and soles, consistent with varicella infection. Concomitantly, his clinical condition rapidly deteriorated. Follow-up laboratory tests showed severe hepatic dysfunction (ALT 1437 U/L, AST \u0026gt;1000 U/L), profound coagulopathy (INR 3.5, markedly prolonged PT/APTT, fibrinogen \u0026lt;0.3 gm/L), leukocytosis (WBC 23.6 \u0026times;10\u0026sup3;/\u0026micro;L), and elevated inflammatory markers (CRP 15.0 mg/L, Procalcitonin 0.12 ng/mL). Varicella polymerase chain reaction (PCR) from vesicular lesions was positive, confirming disseminated varicella zoster infection.\u003c/p\u003e\n\u003cp\u003eHis condition further complicated by hemorrhagic transformation of vesicles, subconjunctival hemorrhage, active bleeding from intravenous sites, and progressive encephalopathy. The patient developed altered mental status with decreased Glasgow Coma Score (GCS), prompting evaluation for hepatic encephalopathy. As a result, investigations were undertaken to exclude other potential causes of acute liver failure, including viral, autoimmune, and drug-induced etiologies. Empiric intravenous acyclovir therapy, broad-spectrum antibiotics (piperacillin-tazobactam), supportive transfusions (fresh frozen plasma (FFP), cryoprecipitate), and intensive care management were promptly initiated.\u003c/p\u003e\n\u003cp\u003eThe patient met clinical and laboratory criteria for disseminated intravascular coagulation (DIC), including prolonged PT/aPTT, elevated INR (4.9), low fibrinogen (\u0026lt;0.3 g/L), and severe thrombocytopenia (platelets: 23 x10^9/L), along with diffuse bleeding from cannula sites, gums, and conjunctiva. Despite maximal supportive interventions including mechanical ventilation, renal replacement therapy for acute renal failure, and vasopressor support for refractory shock, the patient\u0026apos;s condition progressed rapidly to multiorgan failure, DIC, and acute respiratory distress syndrome (ARDS) (Figure 2). The patient unfortunately passed away due to cardiac arrest and multi-organ failure on the sixth day of hospitalization.\u003c/p\u003e\n\u003cp\u003eThis case underscores the critical importance of early recognition of atypical presentations of varicella in adults, particularly when complicated by even low-dose steroid-induced immunosuppression, to prevent catastrophic outcomes.\u003c/p\u003e\n\u003ch2\u003eTable 1:\u003c/h2\u003e\n\u003ch2\u003eHematology:\u003c/h2\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"638\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eWBC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e11--\u0026gt;28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eHgb\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003ehct\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e44.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e46.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eMCV/MCH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003ePlatelets\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e220\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eAbsolute reticulocyte count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eReticulocyte index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eO.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eCoagulation profile:\u003c/h2\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"638\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003ePT (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e40.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e26.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eINR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e3.5--\u0026gt;4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eD-dimer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eUnable to analyze by the machine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eUnable to analyze by the machine\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eFibrinogen (gm/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026lt;0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eaPTT (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e71.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026gt;180\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eChemistry:\u003c/h2\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"638\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDay1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDay2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDay3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eUrea (mmol/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eCreatinine (umol/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e171\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e192\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eNa (mmol/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e138\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eK (mmol/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eCl (mmol/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eHco3 (mmol/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003ePhosphorous (mmol/l(\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eALT (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e46\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e1,437--\u0026gt;2,020\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e1,239\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eAST (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e54\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e1,000--\u0026gt;6,045\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e2,651\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eCK (mmol/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e2,821\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eAmmonia (umol/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e66\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eLipase (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e17\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eCeruloplasmin (mg/dl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e10\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eCRP (mg/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e15\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e3.5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eLactic acid (mmol/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e1.8\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e2.4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e1.7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eProcalcitonin (mg/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e0.12\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e10\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eEndocrinology:\u003c/h2\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"638\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eFerritin (ug/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e64,653\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eToxicology:\u003c/h2\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"638\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eAcetaminophen level (umol/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e11.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eAutoimmune disease:\u003c/h2\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"638\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eASM Ab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003enegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eALKM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003enegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eANA CTD int\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003enegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eC3 (mg/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e88.9\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e72\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eC4 (mg/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e14.3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e14.1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eSerology:\u003c/h2\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"638\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eDAY4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eVaricella Zoster\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eIgM / lgG negative\u003c/p\u003e\n \u003cp\u003ePCR positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eIgM /IgG negative\u003c/p\u003e\n \u003cp\u003ePCR positive\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eMeasles\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eIgM negative\u003c/p\u003e\n \u003cp\u003eIgG positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eHCV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eIgM/IgG/PCR negative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eHBV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eIgM/IgG/PCR negative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eHIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eIgM/IgG/PCR negative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eEBV (IU/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003ePCR positive; 1,455\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 638px;\"\u003e\n \u003cp\u003eAbbreviations: WBC \u0026ndash; White Blood Cell count, Hgb \u0026ndash; Hemoglobin, Hct \u0026ndash; Hematocrit, MCV/MCH \u0026ndash; Mean Corpuscular Volume / Mean Corpuscular Hemoglobin, \u003cstrong\u003ePT sec\u003c/strong\u003e \u0026ndash; Prothrombin Time (in seconds), \u003cstrong\u003eINR\u003c/strong\u003e \u0026ndash; International Normalized Ratio, \u003cstrong\u003eaPTT\u0026nbsp;\u003c/strong\u003e\u0026ndash; Activated Partial Thromboplastin Time, \u003cstrong\u003eNa\u003c/strong\u003e\u0026ndash; Sodium, \u003cstrong\u003eK\u003c/strong\u003e\u0026ndash; Potassium, \u003cstrong\u003eCl\u003c/strong\u003e\u0026ndash; Chloride, \u003cstrong\u003eHCO₃\u003c/strong\u003e\u0026ndash; Bicarbonate, \u003cstrong\u003eALT\u003c/strong\u003e\u0026ndash; Alanine Aminotransferase, \u003cstrong\u003eAST\u003c/strong\u003e\u0026ndash; Aspartate Aminotransferase, \u003cstrong\u003eCK\u003c/strong\u003e\u0026ndash; Creatine Kinase, \u003cstrong\u003eCRP\u003c/strong\u003e\u0026ndash; C-Reactive Protein, \u003cstrong\u003eASM Ab\u003c/strong\u003e \u0026ndash; Anti-Smooth Muscle Antibody, \u003cstrong\u003eALKM\u003c/strong\u003e \u0026ndash; Anti-Liver-Kidney Microsomal Antibody, \u003cstrong\u003eANA\u0026nbsp;\u003c/strong\u003e\u0026ndash; Antinuclear Antibodies, \u003cstrong\u003eHCV\u003c/strong\u003e \u0026ndash; Hepatitis C Virus, \u003cstrong\u003eHBV\u003c/strong\u003e \u0026ndash; Hepatitis B Virus, \u003cstrong\u003eHIV\u003c/strong\u003e \u0026ndash; Human Immunodeficiency Virus, \u003cstrong\u003eEBV\u003c/strong\u003e \u0026ndash; Epstein\u0026ndash;Barr Virus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePCR for varicella from skin swab was positive\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDiagnosis of VZV is often clinical, based on characteristic skin lesions of vesicular exanthem and associated systemic symptoms. However, diagnosis may be challenging in cases presenting with atypical features such as isolated abdominal or back pain, which can precede the rash. Such prodromal symptoms have been documented in children (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and immunocompromised individuals, and in a limited number of reports involving immunocompetent adults as well (\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). These manifestations are thought to result from VZV-related myeloradiculopathy, a recognized neurological complication of the infection (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The diagnosis of fulminant hepatitis was based on established clinical criteria\u0026mdash;acute onset liver dysfunction with an INR\u0026thinsp;\u0026gt;\u0026thinsp;1.5 and hepatic encephalopathy in a patient without preexisting liver disease.\u003c/p\u003e \u003cp\u003eDefinitive diagnosis of VZV can be made using PCR for viral DNA, serology, or direct fluorescent antibody testing. Tzanck smear may show multinucleated giant cells with intranuclear inclusions. Our case demonstrates the diagnostic challenge in recognizing disseminated varicella in its early phase, where initial symptoms mimic non-infectious gastrointestinal or neurologic pathology. Despite early hospital presentation, diagnosis was delayed due to absence of rash and normal imaging. Once the vesicular rash appeared, the disease course progressed rapidly, leading to multiorgan failure. The benefits in this case included early initiation of empirical therpy, with acyclovir, supportive ICU care, and transfusions. However, limitations included delayed consideration of VZV in differential diagnoses, and the use of immunosuppressant (prednisolone 5mg/day) for nonspecific back pain, potentially exacerbating the viral dissemination.\u003c/p\u003e \u003cp\u003eThe differential diagnosis of VZV infection includes smallpox, coxsackievirus, echovirus, rickettsia pox, and atypical measles. Other important considerations are meningococcemia, disseminated gonococcal infection, bullous vasculitis, infectious endocarditis, acute generalized exanthematous pustulosis, pustular psoriasis, and Mucha-Habermann disease.\u003c/p\u003e \u003cp\u003eDisseminated varicella can lead to serious complications, including pneumonia, encephalitis, hepatitis, and hemorrhagic manifestations. Individuals with hematologic or solid organ malignancies, diabetes mellitus, or inherited thrombophilias (such as protein C and S deficiencies) are considered at higher risk for severe disease (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Complications are significantly more common in adults than in children (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Notably, up to 90% of varicella pneumonia cases occur in adults. Less frequent but severe complications include myocarditis, gangrene, retinitis, glomerulonephritis, Reye syndrome, Guillain-Barr\u0026eacute; syndrome (GBS), acute cerebellar ataxia, and disseminated intravascular coagulation (DIC). Patients should be placed under droplet and contact precautions until all vesicular lesions have crusted. Antiviral therapy with intravenous acyclovir should be initiated as early as possible, ideally within four days of rash onset, to reduce morbidity and mortality (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe reviewed the literature for reported cases of disseminated varicella-zoster virus (VZV) infection in immunocompetent adults presenting with fulminant hepatic failure and/or abdominal pain as a primary symptom. Our search, limited to English-language publications, identified approximately 10 individual case reports; no case series or systematic reviews were found (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most patients were reported to be previously healthy without known immunosuppression. However, two patients had comorbidities potentially impacting immune response: one had hepatitis B (case 6), and another had immune thrombocytopenic purpura post-splenectomy (case 10). No cases involved known malignancy, HIV, or long-term immunosuppressive therapy. We performed a structured literature review using PubMed, Scopus, and Google Scholar databases. All the patients had abdominal pain with or without fever at time of presentation. Abdominal and back pain, though non-specific, have been documented in varicella cases as potential early manifestations. These symptoms are hypothesized to result from VZV-induced myeloradiculopathy or visceral neuropathy. The patient\u0026rsquo;s right upper quadrant pain could also be attributed to hepatic inflammation and capsular distension during the early stages of viral hepatitis. Although drug-induced liver injury cannot be entirely excluded, low acetaminophen levels (11.4 \u0026micro;mol/L) and lack of temporal correlation argue against it as the primary cause. All patients received treatment with acyclovir. Hepatic dysfunction was observed in every case, with six patients progressing to fulminant hepatitis. The diagnosis of fulminant hepatitis was based on established clinical criteria\u0026mdash;acute onset liver dysfunction with an INR\u0026thinsp;\u0026gt;\u0026thinsp;1.5 and hepatic encephalopathy in a patient without preexisting liver disease (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Additional complications included DIC, rhabdomyolysis, encephalitis, nephritis, thrombocytopenia, refractory distributive shock, and multiorgan failure involving both respiratory and renal systems. Despite aggressive treatment, five patients died.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCo-morbidities\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePresentation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 years old female\u003c/p\u003e \u003cp\u003ePositive sick contact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo comorbidities, immunocompetent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBack pain radiating to back, fever, then rash appeared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcyclovir and supportive treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatitis, pneumonia, DIC\u003c/p\u003e \u003cp\u003eRecovered\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 years old female\u003c/p\u003e \u003cp\u003ePositive sick contact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo comorbidities; immunocompetent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEpigastric pain, vomiting, fever, rash appeared two days later\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcyclovir and supportive treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatic failure, DIC, pneumonia, multiorgan failure\u003c/p\u003e \u003cp\u003ePassed away\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 years old\u003c/p\u003e \u003cp\u003ePositive sick contact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo comorbidities; immunocompetent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eabdominal pain, fever, vomiting, rash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcyclovir and supportive treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eVaricella hepatitis, DIC, nephritis\u003c/p\u003e \u003cp\u003ePassed away\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 years old female\u003c/p\u003e \u003cp\u003ePositive sick contact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo comorbidities; immunocompetent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEpigastric pain, fever, rash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcyclovir and supportive treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatic failure, DIC.\u003c/p\u003e \u003cp\u003ePassed away\u003c/p\u003e \u003cp\u003eAutopsy proven multiorgan involvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 years old male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eknown asthmatic\u003c/p\u003e \u003cp\u003e(Not on steroids)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFever, abdominal and back pain, rash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcyclovir and supportive treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatic dysfunction, multiorgan failure,\u003c/p\u003e \u003cp\u003ePassed away\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 years old male\u003c/p\u003e \u003cp\u003ePositive sick contact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHepatitis B (not on medications)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRash, fever, abdominal pain, jaundice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcyclovir and supportive treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatic failure, renal failure, DIC, passed away due to multi organ failure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 years old male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo comorbidities; immunocompetent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAbdominal pain, fever, active bleeding from nose and gums, blood in urine and stool\u003c/p\u003e \u003cp\u003eLater developed restlessness and agitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcyclovir and supportive treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatitis dysfunction, DIC, encephalitis, septicemia\u003c/p\u003e \u003cp\u003eRecovered\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 years old male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo comorbidities; immunocompetent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEpigastric pain, later developed rash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcyclovir and supportive treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eARDS, rhabdomyolysis, acute hepatitis, DIC\u003c/p\u003e \u003cp\u003eRecovered\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 years old male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo comorbidities; immunocompetent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRash, fever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcyclovir and supportive treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatitis, pneumonia, rhabdomyolysis, DIC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 years female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImmune thrombocytopenia (ITP) post splenectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eabdominal pain, nausea, fever, sore throat, vesicular rash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcyclovir and supportive treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatitis\u003c/p\u003e \u003cp\u003eRecovered\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOur case closely parallels those previously reported, with an initial presentation of acute abdominal pain in the absence of rash. The rash appeared later, coinciding with worsening liver function, and ultimately progressed to fulminant hepatic failure with multiorgan involvement. Our patient had a history of taking low-dose prednisolone (5 mg daily) for 2 weeks prior to the onset of symptoms. Previous reports of fulminant varicella have described similar outcomes in patients who were taking low-dose steroids, although not all studies provided exact dosages (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAlthough chickenpox is uncommon in adults, it often follows a more severe course with potentially life-threatening complications. This case highlights the importance of considering VZV infection in adults presenting with atypical symptoms such as isolated abdominal or back pain, especially when no clear surgical cause is found. Clinicians must maintain a high index of suspicion for varicella in adults with non-specific prodromal symptoms, as misdiagnosis and delay in treatment can be fatal. Even low-dose steroid therapy may cause sufficient immunosuppression to predispose individuals to disseminated viral infections, including fulminant varicella. This case highlights the importance of considering such risks when prescribing corticosteroids.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthics approval and Consent to participate:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Medical Research Center at Hamad Medical Corporation in Qatar has granted approval for the publication of this case report under the reference number MRC-04-19-132.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConsent for Publication:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of the details of this medical case and any accompanying images was obtained from the next of kin, as the patient is deceased.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAvailability of data and materials:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that supports the finding of this case report are contained within the article. Additional information is available from the corresponding author upon reasonable request and with the approval of relevant ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eCompeting Interest:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report was not funded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthor Contributions:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: \u0026nbsp;Jaweria Akram, Abdul Qadir\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData Curation: Jaweria Akram, Abdul Qadir\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWriting - Original Draft: Jaweria Akram, Abdul Qadir, Hadeel Alfar\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; Review and Editing: Jaweria Akram, Abdul Qadir, Hadeel Alfar, Theresa Paul, Mamunul Islam, Ali Rahil\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgements:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the Qatar National Library (QNL) for open access publication funding of this article.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMilone G, Di Raimondo F, Russo M, Cacciola E Jr, Giustolisi R. Unusual onset of severe varicella in adult immunocompromised patients. Ann Hematol. 1992;64(3):155\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhamed SP, Balkhair A, Krishnan R. Fulminant varicella zoster infection with multiorgan involvement: a case report. Sultan Qaboos Univ Med J. 2008;8(3):339\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Vas Goonewardane APN, Sanjeewa NHR, Perera T, Weerakoon RR. Malignant chickenpox with coagulopathy in a healthy adult female;a case report and review of literature. Galle Med J. 2015;20(2):46\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaur H, et al. Coagulopathy secondary to chicken pox: a case report. Int J Adv Med. 2017;4(6):1706\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaren R, Anderson J, Schwartz NJ, Hunter, et al. Varicella Hepatitis: A Fatal Case in a Previously Healthy, Immunocompetent AdultReport of a Case, Autopsy, and Review of the Literature. Arch Intern Med. 1994;154(18):2101\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarl V, Vartin, Dits H, Frans E, Wilmer A, et al. Varicella zoster infection associated with acute liver failure. Clin Infect Dis. 1998;27:209\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhatti MA, Manglani CB, Khan MA. Fatal case of chickenpox in an Adult: A case report. J Pak Med Assoc. 2004;54(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMostofa Kamal Chowdhury, Siddique AAA, Haque M, Ali S, Biswas S et al. Prodip Kumar Biswas,. Life Threatening Complications of Chicken Pox in a Young Adult. J MEDICINE. 2014;15:55\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoshoku LEE, Nobuyuki ITO, Tomoko INAGAKI, Tatsuya OKAJIMA, Atsushi MURAMATSU, Yoshiyuki ITO, Manabu DOJO, et al. Fulminant Varicella Infection Complicated with Acute Respiratory Distress Syndrome, and Disseminated Intravascular Coagulation in an Immunocompetent Young Adult. Intern Med. 2004;43(12):1205\u0026ndash;09.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrabant AB-DS, Chatellier D, Bourgoin A, Robert R, Ruckes T, et al. Disseminated Varicella With Multiorgan Failure in an Immunocompetent Adult. J Med Virol. 2009;81:747\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorum ML, Zimmerman, Hyman J. Hepatitis Associated with Varicella Infection in an Immunocompetent Adult J. Clin. Gastroenterol. 1996;23(2):165.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArvin A, Ageing. Immunity and Varicella zoster viruses. N Eng J Med. 2005;352:2266\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVinzio S, Lioure B, Goichot B. Varicella in immunocompromised patients. Lancet. 2006;368(9554):2208.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen P, Reynaud J, Pouzol P, et al. Varicella and thrombotic complications associated with transient protein C and protein S deficiencies in children. Eur J Pediatr. 1994;153(9):646\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlmuneef M, Memish ZA, Balkhy HH, Alotaibi B, Helmy M. Chickenpox complications in Saudi Arabia: Is it time for routine varicella vaccination? Int J Infect Dis. 2006;10(2):156\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeterslund NA. Management of varicella zoster infections in immunocompetent hosts. Am J Med. 1988;85(2A):74\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Coagulopathy, disseminated chickenpox infection, fulminant hepatitis, Varicella zoster in immune-competent adults","lastPublishedDoi":"10.21203/rs.3.rs-5710632/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5710632/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eDisseminated varicella infection in adults, particularly those with mild immunosuppression, can lead to severe complications and life-threatening outcomes. Early diagnosis and intervention are critical yet challenging due to atypical presentations.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA previously healthy 26-year-old male presented with severe epigastric and right upper quadrant abdominal pain radiating to the back, nausea, loss of appetite, and constipation. He had been taking oral prednisolone 5mg daily for 2 weeks prior to symptom onset. Initial evaluation showed mild liver enzyme elevation but normal imaging studies. Within two days, he developed widespread vesicular lesions consistent with varicella, rapidly progressing to fulminant hepatic failure, disseminated intravascular coagulation (DIC), acute renal failure, and acute respiratory distress syndrome (ARDS). Despite intensive management including antiviral therapy, antibiotics, supportive transfusions, and mechanical ventilation, the patient unfortunately passed away due to multi-organ failure.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThis case emphasizes the importance of early suspicion and diagnosis of varicella infection in adults presenting with atypical symptoms, even low-dose steroid therapy may cause sufficient immunosuppression to predispose individuals to disseminated viral infections. Timely intervention can significantly influence patient outcomes.\u003c/p\u003e","manuscriptTitle":"Disseminated Chickenpox with Multi-organ Failure in an Immunocompetent Adult. 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