CASE REPORT Severe Acute Visceral Pain from Varicella Zoster Virus Jacqueline M. Hyland, MD, and John Butterworth, MD From the Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina Varicella zoster virus infection often will not present in the characteristic dermatomal distribution of vesicles in patients who have undergone bone marrow transplan- tation. We cared for a 51-yr-old man with severe ab- dominal pain after bone marrow transplantation for non-Hodgkin’s lymphoma. The diagnosis of varicella zoster was not entertained until he developed a diffuse vesicular rash several days after the onset of pain. We report this case to alert others who may be consulted regarding pain management options for similiar oncol- ogy patients. (Anesth Analg 2003;97:1117–8) D isseminated herpes varicella zoster virus (VZV), found exclusively in immunosuppressed pa- tients, may present with severe visceral pain from VZV-induced neuritis (1). In the absence of a cutaneous eruption, so-called visceral zoster is diffi- cult to diagnose (2). Case Reports A 51-yr-old white male presented to another hospital No- vember 18, 2002 with a 3-day history of severe, generalized abdominal pain. The patient was originally diagnosed with stage 3, low-grade follicular non-Hodgkin’s lymphoma in 1997 when he presented with abdominal and lower back pain. At that time, a computerized tomographic (CT) scan showed a peripancreatic mass. Fine needle aspiration of the mass was diagnostic. He received 6 courses of cyclophosph- amide, doxorubicin, vincristine, and prednisone ending in April 1998. He developed recurrent adenopathy in March 2001, when recurrent lymphoma was found in his bone marrow. He was treated at first with rituximab without response. His disease then responded to 3 cycles of rituximab-EPOCH, after which lymphoma could not be found in his bone marrow. In February 2002 a repeat CT scan showed multiple small- scattered lymph nodes in the neck, chest, and abdomen. He was admitted to hospital on May 16, 2002 for large-dose cyclophosphamide and total body irradiation, followed by successful autologous bone marrow transplantation. He was discharged home on June 5, and was well until mid- November 2002 when he developed severe generalized lower abdominal pain. The patient had no history of opioid tolerance or abuse. Physical examination and abdominal radiograph were not diagnostic, so he was sent home from the emergency department of another hospital with oral opioids. The next day he returned complaining of worsening abdominal pain. When a CT scan showed a 4-cm  2-cm mass at the head of the pancreas compressing the duode- num, increasing periaortic lymphadenopathy, and encase- ment of the inferior mesenteric artery he was admitted to hospital. A consulting surgeon suggested nerve impinge- ment by the tumor mass as the etiology for the pain. An IV infusion of hydromorphone 3 mg/h was started. After sev- eral hours, the patient became unresponsive, requiring nal- oxone, whereupon he was transferred to our institution for further management. Our acute pain service was consulted on the day of ad- mission for advice regarding pain control pending definitive treatment of the (presumed) lymphoma recurrence. During our examination the patient described his pain as deep and he could not identify a location on his abdomen where the pain was most severe. The pain was not “crampy,” and it did not radiate. There were no factors that either increased or decreased the pain. There was no associated nausea. He was given hydromorphone patient-controlled analgesia with a basal rate of 1 mg/h, a 1-mg demand bolus, and a 10-min lockout interval, for a maximum of 5 mg/h. Despite these settings and a reduced respiratory rate, the patient continued to be in excruciating pain (pain score was 8 of a maximum of 10). Because of the lack of a history of opioid tolerance and the lack of response to generous doses of opioid, celiac plexus block was contemplated in the hope of improving analgesia and reducing his opioid needs, pend- ing diagnosis and definitive treatment of the pancreatic mass. A biopsy of the mass showed recurrence of lym- phoma. Shortly thereafter he demonstrated the typical ve- sicular eruption of varicella over his face, chest, arms, and legs, and a diagnosis of disseminated VZV was made. The patient was given IV acyclovir (10 mg/kg every 8 h) while continuing the hydromorphone. The patient’s abdominal pain resolved over 3 days, and he was rapidly weaned from all analgesics and was discharged home a week later. De- finitive treatment of his recurrent lymphoma with chemo- therapy was planned. Accepted for publication May 30, 2003. Address correspondence to: Dr. Butterworth, Department of An- esthesiology, Wake Forest University School of Med, Medical Cen- ter Boulevard, Winston-Salem, NC 27157–1009. Address email to jbutter@wfubmc.edu. DOI: 10.1213/01.ANE.0000081789.58565.31 ©2003 by the International Anesthesia Research Society 0003-2999/03 Anesth Analg 2003;97:1117–8 1117