From the Guidelines
Varicella Zoster virus (VZV) infection can cause abdominal pain, particularly when it presents as herpes zoster (shingles) affecting the thoracic or lumbar dermatomes. When VZV reactivates in the sensory ganglia that supply the abdominal region (typically thoracic dermatomes T7-T12), patients may experience significant abdominal pain before the characteristic rash appears. This pre-eruptive pain, which can last 1-5 days before rash onset, is often misdiagnosed as appendicitis, cholecystitis, or other intra-abdominal conditions. The pain typically follows a dermatomal distribution and may be described as burning, stabbing, or deep and can be severe enough to warrant emergency evaluation. In rare cases, VZV can cause visceral zoster affecting internal organs without skin manifestations, potentially causing abdominal pain from direct viral involvement of abdominal organs. Treatment includes antiviral medications like acyclovir (800mg five times daily), valacyclovir (1g three times daily), or famciclovir (500mg three times daily) for 7 days, ideally started within 72 hours of rash onset, as recommended by guidelines such as those from the Infectious Diseases Society of America 1. Pain management may require analgesics ranging from NSAIDs to opioids depending on severity. The abdominal pain occurs because the virus causes inflammation of the affected nerves, leading to neuropathic pain along their distribution. Key considerations in managing VZV infections include preventing viral reactivation with oral antivirals in high-risk patients, such as those with immunosuppression, and promptly treating any reactivation to prevent complications like dissemination or chronic ulcerations 1. Given the potential for severe pain and complications, early recognition and treatment of VZV infection are crucial to improve outcomes and quality of life for affected patients. It's also important to note that while the provided studies 1 discuss various aspects of VZV infection and its management, the most relevant and recent guidance for clinical practice is found in more specialized guidelines like those for the diagnosis and management of skin and soft-tissue infections 1.
From the Research
Varicella Zoster Infection and Abdominal Pain
- Varicella Zoster infection can cause abdominal pain, as evident from several case reports and studies 2, 3, 4, 5.
- The infection can lead to severe abdominal pain, which may be associated with periarterial fat stranding on computed tomography (CT) scans 2, 4.
- In some cases, Varicella Zoster infection can cause acute pancreatitis, which is characterized by abdominal pain, elevated levels of urine and serum amylase, and findings of peri-pancreatic exudation and effusions on CT and magnetic resonance cholangiopancreatography 3, 5.
- Visceral disseminated Varicella Zoster infection can also cause acute abdomen, which may present with severe abdominal pain and unremarkable CT findings initially 4.
- The infection can affect both immunocompromised and immunocompetent individuals, although the risk of complications is higher in immunocompromised patients 3, 5.
- Treatment with antiviral drugs such as acyclovir can help alleviate symptoms, including abdominal pain, and improve outcomes 2, 3, 4, 5.
Specific Cases and Findings
- A case report described a 62-year-old woman with multiple myeloma who developed disseminated Varicella Zoster infection with abdominal pain and periarterial fat stranding on CT scans 2.
- Another case report described a 44-year-old immunocompetent woman who developed acute pancreatitis associated with Varicella Zoster infection, presenting with vomiting and persistent pain in the upper quadrant 3.
- A case report also described a 61-year-old woman with well-controlled diabetes mellitus who developed visceral disseminated Varicella Zoster infection with severe abdominal pain and fat stranding around the celiac and superior mesenteric arteries on CT scans 4.
- A renal transplant recipient developed Varicella Zoster virus-induced pancreatitis and hepatitis, presenting with severe pain in the epigastrium radiating to his back and elevated serum lipase levels 5.