Body Under Attack: Disseminated Varicella-Zoster Virus Infection

Varicella-zoster virus (VZV) infection is typically benign and self-limiting. In adults, it most commonly manifests as a localized cutaneous infection. However, in immunocompromised individuals, VZV can undergo hematogenous dissemination and cause severe visceral involvement, including pulmonary, hepatic, pancreatic, cardiac, and central nervous system complications. Disseminated disease may be further complicated by multiorgan failure, acute respiratory distress syndrome (ARDS), and coagulopathy and is associated with significant mortality. We report a 64-year-old man who presented to the emergency department with fever and abdominal pain, followed by a generalized rash with cephalocaudal progression involving the trunk and upper limbs. He was diagnosed with disseminated VZV infection, which was complicated by hepatitis, acute pancreatitis, and severe pneumonia, progressing to ARDS. The patient was admitted to the intensive care unit (ICU) and started on invasive mechanical ventilation. Early initiation (2nd day after ICU admission) of intravenous acyclovir was critical to a favorable clinical outcome, allowing discharge from the ICU on the 10th day. Disseminated VZV infection may initially present with visceral manifestations, particularly abdominal pain, which can precede or occur in the absence of a typical vesicular skin rash, leading to diagnostic delay. Although VZV pneumonia complicated by ARDS is rare, it carries high morbidity and mortality. Early recognition, prompt antiviral therapy, and supportive intensive care management are crucial to improve outcomes. This case highlights the importance of maintaining a high index of suspicion for VZV infection in critically ill patients with unexplained systemic or respiratory severe deterioration, particularly in those with underlying immune dysfunction. Prompt recognition and treatment, as well as biopsy of the lesions, are essential to improve the prognosis of these immunocompromised patients at high risk for atypical infectious diseases.