acyclovir and Multiple-Organ-Failure

We describe a rare fulminant case of Epstein-Barr virus-associated hemophagocytic syndrome (HPS) in a 37-year-old female renal transplant patient, indistinguishable from severe sepsis clinically and in the laboratory. HPS involves rapidly escalating immune system activation, resulting in a cytokine cascade, which can, especially in immunocompromised patients, lead to multi-organ failure, and even death. Thirty-two Herpesviridae-associated HPS cases in renal transplant patients have been reported and are reviewed. Overall mortality is 47% (15/32 cases).

Topics: Acyclovir; Antiviral Agents; Diarrhea; Drug Therapy, Combination; Epstein-Barr Virus Infections; Fatal Outcome; Female; Fever; Ganciclovir; Glomerulonephritis, IGA; Herpesvirus 4, Human; Humans; Immunocompromised Host; Immunosuppressive Agents; Kidney Transplantation; Lymphohistiocytosis, Hemophagocytic; Multiple Organ Failure; Oliguria

A 12-year-old female patient with biliary atresia underwent living donor liver transplantation (LDLT). Twelve months after the LDLT, she developed acute hepatitis (alanine aminotransferase 584 IU/L) and was diagnosed with disseminated varicella-zoster virus (VZV) infection with high level of serum VZV-DNA (1.5 × 10(5) copies/mL) and generalized vesicular rash. She had received the VZV vaccination when she was 5-years-old and had not been exposed to chicken pox before the LDLT, and her serum was positive for VZV immunoglobulin G at the time of the LDLT. Although she underwent treatment with intravenous acyclovir, intravenous immunoglobulin, and withdrawal of immunosuppressants, her symptoms worsened and were accompanied by disseminated intravascular coagulation, pneumonia, and encephalitis. These complications required treatment in the intensive care unit for 16 days. Five weeks later, her clinical findings improved, although her VZV-DNA levels remained high (8.5 × 10(3)copies/mL). Oral acyclovir was added for 2 weeks, and she was eventually discharged from our hospital on day 86 after admission; she has not experienced a recurrence. In conclusion, although disseminated VZV infection with multiple organ failure after pediatric LDLT is a life-threatening disease, it can be cured via an early diagnosis and intensive treatment.

Topics: Acyclovir; Antibodies, Viral; Chickenpox; Child; DNA, Viral; Exanthema; Female; Herpesvirus 3, Human; Humans; Immunocompromised Host; Immunoglobulin G; Immunoglobulins, Intravenous; Liver Transplantation; Living Donors; Multiple Organ Failure; Transplant Recipients; Treatment Outcome; Viral Load

A middle-aged man with decompensated cirrhosis and a dimorphic multisite skin rash is diagnosed with rare atypical herpes simplex infection, manifesting Sweet's syndrome (SS) in the absence of other described associations. SS, an acute febrile neutrophilic dermatosis, has three common forms-classical or idiopathic, malignancy associated and drug induced. Systemic autoimmune, connective tissue diseases and infections are also strong associations. The latter is commonly described in Gram-positive bacteria, salmonellosis and

Topics: Acyclovir; Antiviral Agents; Fatal Outcome; Herpes Simplex; Humans; Liver Cirrhosis; Male; Middle Aged; Multiple Organ Failure; Sepsis; Skin Diseases, Vesiculobullous; Sweet Syndrome

Pyogenic tonsillitis may often be observed in the general Western population. In severe cases, it may require antibiotic treatment or even hospitalization and often a prompt clinical response will be noted. Here we present an unusual case of progressive multiple organ failure including fulminant liver failure following acute tonsillitis initially mistaken for "classic" pyogenic (that is bacterial) tonsillitis.. A 68-year-old previously healthy white man was referred with suspicion of pyogenic angina. After tonsillectomy, he developed acute liver failure and consecutive multiple organ failure including acute hemodynamic, pulmonary and dialysis-dependent renal failure. Immunohistopathological analysis of his tonsils and liver as well as serum polymerase chain reaction analyses revealed herpes simplex virus-2 to be the causative pathogen. Treatment included high-dose acyclovir and multiorgan supportive intensive care therapy. His final outcome was favorable.. Fulminant herpes simplex virus-2-induced multiple organ failure is rarely observed in the Western hemisphere and should be considered a potential diagnosis in patients with tonsillitis and multiple organ failure including acute liver failure. From a clinical perspective, it seems important to note that fulminant herpes simplex virus-2 infection may masquerade as "routine" bacterial severe sepsis/septic shock. This persevering condition should be diagnosed early and treated goal-oriented in order to gain control of this life-threatening condition.

Topics: Acute Disease; Acyclovir; Aged; Antiviral Agents; Critical Care; Herpes Simplex; Herpesvirus 2, Human; Humans; Liver; Liver Failure, Acute; Male; Multiple Organ Failure; Tonsillitis; Treatment Outcome

Topics: Acyclovir; Adult; Antiviral Agents; Female; Herpes Zoster; Herpesvirus 3, Human; Humans; Multiple Organ Failure; Skin

We describe a death in a 15-mo-old girl who developed a varicella-like rash 20 d after varicella vaccination that lasted for 2 mo despite acyclovir treatment. The rash was confirmed to be due to vaccine-strain varicella-zoster virus (VZV). This is the first case of fatal varicella due to vaccine-strain VZV reported from the United States. The patient developed severe respiratory complications that worsened with each new crop of varicella lesions; vaccine-strain VZV was detected in the bronchial lavage specimen. Sepsis and multi-organ failure led to death. The patient did not have a previously diagnosed primary immune deficiency, but her failure to thrive and repeated hospitalizations early in life (starting at 5 mo) for presumed infections and respiratory compromise treated with corticosteroids were suggestive of a primary or acquired immune deficiency. Providers should monitor for adverse reactions after varicella vaccination. If severe adverse events develop, acyclovir should be administered as soon as possible. The possibility of acyclovir resistance and use of foscarnet should be considered if lesions do not improve after 10 d of treatment (or if they become atypical [e.g., verrucous]). Experience with use of varicella vaccine indicates that the vaccine has an excellent safety profile and that serious adverse events are very rare and mostly described in immunocompromised patients. The benefit of vaccination in preventing severe disease and mortality outweigh the low risk of severe events occurring after vaccination.

Topics: Acyclovir; Antiviral Agents; Chickenpox; Chickenpox Vaccine; Fatal Outcome; Female; Herpesvirus 3, Human; Humans; Infant; Multiple Organ Failure; Sepsis; Treatment Failure; United States

Most adults are Varicella zoster virus (VZV)-positive at the age of 20 years. Some, however, remain antibody-negative and may develop primary chicken pox during adulthood. We report a patient with Williams-Campbell syndrome who underwent double-lung transplantation while being VZV-negative. One year after the successful procedure, he was admitted with fulminant hepatic failure and some cutaneous vesicles in his face. Despite a rapid diagnosis of VZV infection and treatment with acyclovir, his situation deteriorated within 24 hours and while awaiting an urgent liver transplantation, he developed multiple organ failure and died.

Topics: Acyclovir; Adult; Antiviral Agents; Bronchiectasis; Chickenpox; Fatal Outcome; Herpesvirus 3, Human; Humans; Liver Failure, Acute; Liver Transplantation; Lung Transplantation; Male; Multiple Organ Failure; Respiratory Insufficiency; Time Factors; Waiting Lists

Varicella is a common and mild disease in healthy children. However, when patients are in immunocompromised conditions, such as receiving chemotherapy for cancer treatment, they are highly vulnerable and it can even prove lethal. Herein, we report a 14-year-old boy with acute lymphoblastic leukemia who was receiving chemotherapy for induction with vincristine, idarubicin, L-asparaginase, and prednisolone, presented with typical varicella skin lesions and varicella-zoster virus was detected in his serum by real-time polymerase chain reaction (PCR). His condition was advanced to multiple organs failure, including fulminant hepatitis, disseminated intravascular coagulation, and myocarditis despite acyclovir administration. After a combined therapy with intravenous acyclovir and high-dose intravenous immunoglobulin, his condition was dramatically improved. We suggest that IVIG may be used immediately with acyclovir when immunocompromised patients with varicella advanced to dissemination are identified.

Topics: Acyclovir; Adolescent; Antiviral Agents; Chickenpox; Combined Modality Therapy; Humans; Immunocompromised Host; Immunoglobulins, Intravenous; Male; Multiple Organ Failure; Precursor Cell Lymphoblastic Leukemia-Lymphoma

Topics: Acyclovir; Adolescent; Antiviral Agents; Aspergillosis; Azathioprine; Brain; Chickenpox; Disseminated Intravascular Coagulation; Fatal Outcome; Female; Humans; Immunosuppressive Agents; Lung; Lupus Erythematosus, Systemic; Lymphohistiocytosis, Hemophagocytic; Meninges; Multiple Organ Failure; Myocardium; Opportunistic Infections; Prednisolone

A 73-year-old man with multiorgan failure requiring mechanical ventilation and haemodialysis developed herpes labialis infection during his stay in the ICU. This was treated with enteral acyclovir. He developed persistent neurologic impairment soon after acyclovir administration, which, over the course of seven days, progressed to coma, the aetiology of which was unclear. The computed tomograph (CT) of the brain and the cerebrospinal fluid (CSF) examination was normal. The electroencephalogram (EEG) showed generalized slowing. The possibility of acyclovir neurotoxicity was considered and the drug was discontinued. Haemodialysis was instituted and the patient made a complete neurological recovery. We believe that this is the first reported case of coma due to enteral acyclovir.

Topics: Acyclovir; Administration, Oral; Aged; Antiviral Agents; Brain; Cerebrospinal Fluid; Coma; Critical Care; Critical Illness; Electroencephalography; Herpes Labialis; Humans; Male; Multiple Organ Failure; Renal Dialysis; Respiration, Artificial; Tomography, X-Ray Computed

We report our experience with two patients with adult onset of chickenpox in the setting of longstanding steroid therapy for nephrotic syndrome. Ours is a 430-bed tertiary care teaching hospital, The Wellesley Hospital, Toronto, Ontario. Both patients presented as self-referrals to the emergency department.. The clinical suspicion of chickenpox was rapidly confirmed in both cases by a Tzanck smear preparation, by viral cultures of the vesicle, serology, and skin biopsy. In both patients therapy with high dose acyclovir, 10 mg/kg q8h, intravenously, was instituted based on clinical presentation.. Delay in clinical recognition and treatment in our first case resulted in death due to multiorgan failure (MOF). Improved awareness and rapid treatment of the second patient had a favorable outcome with no sequelae.. Chickenpox is not only a childhood illness. Although rare in the adult population, it is associated even in the nonimmunocompromised host with increased morbidity and mortality. Steroid therapy predisposes to early dissemination and a potentially fatal outcome. Adults with immunosuppression should receive prompt systemic treatment with acyclovir.

Topics: Acyclovir; Adult; Chickenpox; Fatal Outcome; Humans; Male; Multiple Organ Failure; Nephrotic Syndrome; Prednisone

To determine the incidence and clinical course of veno-occlusive disease of the liver (VOD) after bone marrow transplantation and to analyze risk factors for severe VOD.. Cohort study of 355 consecutive patients.. A bone marrow transplantation center.. Each patient was prospectively evaluated for VOD, and many risk factors for severe VOD were analyzed using logistic regression models. The relation of VOD to renal and cardiopulmonary failure was analyzed using time-dependent proportional hazards models.. Veno-occlusive disease developed in 190 of 355 patients (54%; 95% CI, 48% to 59%): Fifty-four patients had severe VOD and 136 had mild or moderate VOD. Independent variables derived from a multivariate model for predicting severe VOD included elevated transaminase values before transplantation (relative risk, 4.6; P < 0.0001); vancomycin therapy during cytoreductive therapy (relative risk, 2.9; P = 0.003); cytoreductive therapy with a high-dose regimen (relative risk, 2.8; P = 0.01); acyclovir therapy before transplantation (relative risk, 4.8; P = 0.02); mismatched or unrelated donor marrow (relative risk, 2.4; P = 0.02); and previous radiation therapy to the abdomen (relative risk, 2.2; P = 0.04). Vancomycin therapy was a marker for persistent fever. Multiorgan failure was more frequent among patients with VOD and usually followed the onset of liver disease.. Veno-occlusive disease, which developed in 54% of bone marrow transplant recipients, is frequently associated with renal and cardiopulmonary failure. Pretransplant transaminase elevations, use of high-dose cytoreductive therapy, and persistent fever during cytoreductive therapy are independent predictors of severe VOD.

Topics: Acyclovir; Adolescent; Adult; Aged; Blood Component Transfusion; Bone Marrow Transplantation; Child; Child, Preschool; Female; Hepatic Veno-Occlusive Disease; Hepatitis; Humans; Incidence; Infant; Logistic Models; Male; Middle Aged; Multiple Organ Failure; Multivariate Analysis; Prospective Studies; Risk Factors; Transaminases; Vancomycin