Severe Disseminated Varicella Zoster in an Immunocompetent Adolescent: A Case Report

We present the case of an immunocompetent, fully vaccinated 17-year-old female who developed severe, disseminated varicella-zoster virus (VZV) reactivation with visceral involvement, Ramsay Hunt Syndrome, and complications of suspected superimposed bacterial cellulitis, chronic pain, as well as postherpetic neuralgia. We aim to highlight the importance of early recognition and multidisciplinary management of varicella-zoster virus in immunocompetent patients to minimize disease complications. All data were obtained from the electronic medical record with permission from the patient and her parent. The patient underwent serial dermatologic examinations and a comprehensive immunologic workup. Positive VZV PCR testing of the lesion and blood confirmed active VZV infection. Despite an intensive multi-drug antiviral regimen, she developed suspected clinical drug resistance-although resistance testing was not performed-progressing to disseminated varicella with hepatic involvement. Inpatient complications included Ramsay Hunt Syndrome, suspected superimposed bacterial cellulitis, opioid withdrawal, and chronic pain. While outpatient, she developed postherpetic neuralgia and psychosocial impairment, preventing her from completing her academic year. This case illustrates a rare, but severe presentation of disseminated varicella-zoster virus with visceral involvement and concomitant Ramsay Hunt Syndrome in a healthy adolescent. It underscores the importance of considering VZV in the differential diagnosis of pediatric rash and neuropathy in all patients, irrespective of immune status.