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\begin{document}

\title{A Case of Varicella Zoster Infection in Kidney Transplant Recipient
using immunosuppressant}



\author[1]{Abdirahim Ali Nur  Adam}%
\author[1]{Abdulrashid Hashi Mohamed}%
\author[1]{Mohamed Osman Omar Jeele}%
\affil[1]{Somalia Mogadishu Turkey Recep Tayyip Erdogan Training and Research Hospital}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\textbf{Introduction:}

To prevent acute or chronic allograft rejection, recipients of kidney
transplants are needed to take immunosuppressive for the rest of their
lives. However, their compromised immune system put them at risk for
opportunistic infections as well\textsuperscript{1}. Infection with the
varicella-zoster virus (VZV) is an unusual in recipients of kidney
transplants at a frequency rate from 1\% to 11\%, but the severity is
more significant in transplant patients compared to the overall
population \textsuperscript{2, 3}. Fever and a self-limiting rash on the
skin and occasionally the mucosa may be the present symptoms of
varicella infection. Additionally observed symptoms include headache,
malaise, and appetite loss. The rash starts off as macules, quickly
develops into papules and then goes through a vesicular stage and crusts
over the lesions. After one to two weeks, crusts flake
off\textsuperscript{4}. Disseminated herpes zoster (HZ) in kidney
transplant recipients can result in a very high overall mortality rate
of up to 30\% \textsuperscript{5}.

Here we describe a 23-year-old male patient with a history renal
transplant who presented to the emergency department with complaint of
high grade fever, chills and generalized rash for 5 days.

\textbf{Case presentation:}

A 23-year-old male patient presented to the emergency department with a
complaint of high grade fever, chills and generalized rash for 5 days.
The patient was diagnosed with the end-stage renal disease 4 years ago
which he was put on routine hemodialysis program for 1 year. He
underwent renal transplant 3 years ago and since then he did not needed
any hemodialysis sessions. Following his renal transplant surgery the
patient was put under immunosuppressants drugs (mycophenolate mofetil,
steroids and tacrolimus). He had no known history of chickenpox at young
age, no history of diabetes. He never had any vaccination following his
renal transplant including varicella vaccine. There was no history of
contact with chickenpox patient.

On presentation, the patient was fully conscious, alert and co-operative
and with the following vital signs: BP 145/90 mmHg, pulse 90 times per
minute, RR 14 bpm, and temperature 38.6 \selectlanguage{ngerman}°C. On examination, there was no
jaundice or anemic conjunctiva. He had no palpable lymph nodes,
discomfort, or stiffness in the neck. The rashes were variously healed
widespread erythematous papules and vesicles in the face and trunk
(Figure 1). Chest examination was within normal limit with no rales or
wheezing. He had normal bowel sounds on abdominal examination with no
organomegaly. Limb examination showed adequate turgor and no edema,
inguinal lymph nodes were not palpable. Blood tests revealed a
hemoglobin (Hb) level of 16.6 g/dl, hematocrit (Ht) 49.8\%, leukocyte
7.60/mm3, platelet 200,000/mm3, MCV 87.9 fl, MCH 29.4pg, MCHC 33.4,
creatinine 0,82mg/dl, urea 34 mg/dl random blood glucose (RBS) 110mg/dl,
Sodium 142mEq/l, potassium 3,84mEq/l. Urine examination was
unremarkable. Abdominal ultrasonography only revealed bilateral atrophic
kidneys and transplanted kidney in the pelvic region.

The patient was admitted to infectious disease department under the
diagnosis of chickenpox infection using clinical assessment. He was
started with intravenous acyclovir 3x750mg for 5 days which was later
switched to oral acyclovir 5*800mg and acyclovir lotion and
antipyretics.

As his rash started subsiding with normal temperature he was discharged
to home with close monitoring. After 3 weeks the patient came for
follow-up his rashes had drastically improved and had no fever or chills
(figure 2).

\textbf{Discussion:}

Kidney transplantation is a therapeutic choice for end-stage renal
disease. Kidney transplantation offers the patients a better quality of
life as they are free from fluid and potassium restriction, better
metabolic function and normal hemoglobin as normal kidney function
return\textsuperscript{6}. Immunosuppressants are essential for the
allograft function to be successful. These medications functions by
reducing the allograft rejection response and are used for maintenance,
treating rejection reactions, and induction (strong immunosuppression in
the early days after transplantation). However, using immunosuppressants
also has drawbacks\textsuperscript{6}. The body will be more vulnerable
to a variety of opportunistic infections due to the body's immune system
being suppressed, which can both jeopardize the outcome of kidney
transplants and result in fatalities\textsuperscript{7, 8}. Up to
44.9--82\% of recipients of kidney transplants get infections
postoperatively, including viral infections like cytomegalovirus and
varicella as well as urinary tract infections and pneumonia. The highest
percentages of infections among patients who are on immunosuppressants
are caused by bacteria, fungi, and viruses in 50\%, 30\%, and 5\%,
respectively; while 15\% of infections are considered as
polymicrobial\textsuperscript{9} . Fever, pneumonia, enteritis,
meningitis, and encephalitis are some of the clinical manifestations of
viral infections. As a result, the immune system is suppressed, which
raises the risk of opportunistic infections\textsuperscript{10}.

For the past three years, our patient has been living with a
transplanted kidney and during that time there have been no complaints.
He was using corticosteroids, mycophenolate mofetil, and tacrolimus as
his three immunosuppressants.

Rapid diagnosis is necessary to select the appropriate antiviral therapy
in immunocompromised patients at the time of acute VZV infection. Tissue
culture can be used to isolate VZV; this technique is not, however,
quick enough to affect therapeutic decision-making. The virological
assay to identify VZV antigens using monoclonal antibodies is the
quickest test. Due to a lack of resources, neither culture isolation nor
any other techniques were used to diagnose this patient. The clinical
signs actually showed varicella infection
(chickenpox)\textsuperscript{11}.

Giving an antiviral medication as soon as possible, preferably within
the first 24 hours after the rash initially starts, will produce the
best results. Antiviral medication can be substituted orally if clinical
improvement occurs\textsuperscript{12}.

Although being the high risk group for infections, Vaccinations had
never been administered to our patient before. Some recommendations call
for the delivery of vaccines to every patient receiving an organ
transplant. Seronegative individuals should receive two doses of
pre-transplant immunization, spaced four weeks apart, to help prevent
serious infection. The chosen vaccine must be suitable for chronic
kidney disease patients\textsuperscript{13}.

\textbf{Conclusions:}

Patients undergoing kidney transplants frequently have immunosuppressive
conditions, making them more susceptible to infection. The
varicella-zoster virus vaccine is required to protect the kidney
transplant patient from infection. Antiviral medication should be taken
into consideration if kidney transplant recipients have a serious
varicella infection.

Abbreviations

VZV: Varicella-zoster virus

HZ: Herpes zoster

\textbf{Ethics Committee approval and consent for publication:}

Mogadishu-Somali Turkish Training and Research Hospital ethics committee
waived approval for this case report. Written informed consent was
obtained from the patient to publish the details and the images in this
case report anonymously.

\textbf{Acknowledgments}

N/A

\textbf{Funding}

The authors declare no funding source for this research.

\textbf{Disclosure}

The authors declare no competing interests in relation to this study.

\textbf{Reference}

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