Spontaneous splenic rupture complicating primary varicella zoster infection: a case report
Uthayakumar and Harrington BMC Res Notes
Spontaneous splenic rupture complicating primary varicella zoster infection: a case report
Aarthy Uthayakumar 0
David Harrington 1
0 University College London Hospitals NHS Trust , 235 Euston Road, London , UK
1 Charing Cross Hospital, Imperial College London NHS Healthcare Trust , London , UK
Background: Primary varicella zoster virus (VZV) infection is a common illness, predominantly affecting children. Its course is typically benign, although severe complications have been described. Splenic rupture is an extremely rare and potentially fatal complication of primary VZV infection, with only a handful of cases reported in the literature. Case Presentation: A 32-year-old Romanian man with no significant past medical history, presented with a 2 day history of sudden onset, worsening generalised abdominal pain and a 1 day history of vomiting. The following day he developed fevers and a generalised widespread erythematous rash consisting of clusters of macules, papules and vesicles at different stages of development. There was no history of sore throat, coryza, arthralgia, myalgia, cough, shortness of breath, weight loss, or night sweats. There was no recent illness and no history of trauma. CT abdomen showed splenic rupture with intra-abdominal haemorrhage. Admission bloods showed anaemia and thrombocytopenia, with haemoglobin 110 g/l and platelets 78 × 109/l. Viral PCR of vesicle fluid from the rash was positive for VZV DNA confirming the clinical diagnosis of primary varicella zoster infection. Viral serology also confirmed recent infection. He was haemodynamically resuscitated, and underwent laparotomy and splenectomy. He was commenced on IV acyclovir and completed a 5 day course. Prior to discharge he was commenced on recommended splenectomy secondary prevention treatment. Conclusion: There are several reported complications of varicella infection, more commonly in the immunocompromised population. Spontaneous splenic rupture is an unusual complication of primary VZV infection. Here we report the sixth known case in the literature. Splenic rupture should be considered in cases of primary varicella in young adults presenting with abdominal pain.
VZV; Splenic rupture
Primary varicella zoster virus (VZV) is a ubiquitous virus
of the family herpesviridae. Infection is typically seen in
childhood, and typically follows a benign, self-limiting
course. It is highly infectious, spread by close contact or
respiratory droplets, with the secondary infection rate
from a household contact of chickenpox as high as 90%
This case highlights a potentially life threatening
complication of a common infection caused by an ubiquitous
virus, which may easily be missed if not considered. It is
the 6th report of this complication developing secondary
to VZV, which infects approximately 90% of people by
A 32-year-old Romanian man presented with a 2 day
history of sudden onset, worsening generalised abdominal
pain and a 1 day history of vomiting. On the day after
admission he developed fevers and a generalised rash
which was neither itchy nor painful. There was no history
of sore throat, coryza, arthralgia, myalgia, cough,
shortness of breath, weight loss, or night sweats. There was no
recent illness and no history of trauma.
There was no significant past medical history or
previous surgery. He had no known history of chickenpox. He
took no medications of any kind. He was a heavy smoker,
and reported minimal alcohol intake. He was originally
from Romania, and had lived in the UK for 7 months. He
had no other travel history. He lived alone and had one
regular female sexual partner for the past 3 months.
On examination he was alert and comfortable. His
pulse was 110 bpm, blood pressure 145/100 mmHg,
respiratory rate 24/min, temperature 37.2 °C, oxygen
saturations 97% on room air. He had a widespread
erythematous rash consisting of clusters of macules, papules
and vesicles at different stages of development, worse
on upper limbs, torso, and back. The chest was clear to
auscultation and the abdomen was generally tender, with
a palpable enlarged spleen. There was no guarding or
percussion tenderness. Neurological examination was
Admission bloods (see Table 1) showed haemoglobin
(Hb) 110 g/l, white cell count (WCC) 3.6 × 109/l, with
lymphocyte count of 0.6 × 109/l, platelets 78 × 109/l.
C-reactive protein (CRP) was 59 mg/l. Clotting screen,
renal function, liver function and amylase were
normal. Hepatitis B surface antigen hepatitis C antibody,
and HIV (human immunodeficiency virus) 1 and 2
antibody tests were negative. Epstein barr virus (EBV)
serology was viral capsid antigen (VCA) IgM negative,
VCA IgG negative, and Epstein Barr Nuclear Antigen
(EBNA) IgG positive, consistent with infection more
than 8 weeks previously. Cytomegalovirus (CMV) IgG
was positive, and CMV IgM negative, consistent with
previous infection. Serum VZV IgM was negative,
serum VZV IgG equivocal (value 0.65 mIU/ml;
reference range-negative < 0.65 mIU/ml, equivocal 0.65–
0.9 mIU/ml, positive > 0.9 mIU/ml), and polymerase
chain reaction (PCR) of vesicle fluid from the rash was
positive for VZV DNA and negative for herpes simplex
virus (HSV) DNA, confirming the clinical diagnosis of
primary varicella zoster infection.
Subsequent CT of the abdomen and pelvis showed a
splenic rupture of an enlarged spleen (18 cm diameter)
with visible capsular haematoma, and extensive high
density intra-abdominal free fluid surrounding the spleen
and liver, in keeping with haemorrhage (see Fig. 1). The
bowel, liver, biliary system, adrenals, pancreas, kidneys
and bladder were normal. An ultrasound guided
aspiration of the free intra-abdominal fluid revealed frank
blood. Subsequent CT angiogram did not identify a
bleeding point and illustrated stable appearances of
intraabdominal free fluid.
IV acyclovir 10 mg/kg, 8-hourly and oral co-amoxiclav
625 mg 8-hourly were started on admission. Two units
of packed red cells and one pool of platelets were
transfused alongside IV 0.9% sodium chloride solution, before
undergoing laparotomy and splenectomy on day two of
the admission. Surgical findings were of gross peritoneal
blood, and ruptured splenic capsule with large adherent
haematoma. Histological analysis of the spleen showed
normal tissue, with no evidence of amyloid,
haematological malignancy or EBV.
He remained alert and haemodynamically stable
throughout the perioperative period. He improved
clinically and biochemically, with normalisation of the
thrombocytopenia and lymphopenia seen on admission. His
rash significantly improved, with only a small number
of crusted vesicles still present at time of discharge.
Coamoxiclav was stopped after laboratory confirmation of
the diagnosis; IV acyclovir was changed to an oral
formulation after 4 days, with 5 days acyclovir being given in
total. Lifelong prophylactic penicillin V was commenced
before discharge, with early follow up booked to
administer meningococcus ACWY, conjugate
pneumococcus, haemophilus influenzae B, and seasonal influenza
He remained well at follow up, with no sign of on-going
or recurrent disease.
Discussion and conclusions
Primary VZV infection causes chickenpox, which is
characterised by a prodrome of fever and malaise, which may
be absent, followed by a widespread vesicular rash which
typically starts on the face and scalp before spreading to
the torso and back, and then the limbs. Lesions may be
sparse or numerous, and are seen in different stages of
development. The infectious period is 2 days before the
onset of the rash, and the patient is non-infectious when
all lesions have crusted over. Latency is then established
in the sensory ganglia, and may reactivate as shingles in
later life. Seropositivity is seen in up to 90% of adults [
Severe complications are described, and infections can
be more serious in the adult or immunocompromised
population. Secondary bacterial infections, pneumonitis,
meningoencephalitis are well described and are
associated with high mortality and morbidity [
ataxia is the commonest neurological complication and
carries a good prognosis [
]. Transverse myelitis,
Guillain-Barré syndrome, thrombocytopenia, haemorrhagic
varicella, purpura fulminans, glomerulonephritis,
myocarditis, arthritis, orchitis, uveitis, iritis, and hepatitis
have also been rarely described [
]. Splenic rupture is an
extremely rare complication of primary VZV infection
with only a handful of cases reported in the literature.
Splenic rupture is more commonly associated with other
herpesviridae, notably in glandular fever (infectious
mononucleosis) caused by Epstein-Barr virus (EBV), where it
complicates 0.1–0.5% of cases [
], and is typically seen in
young adults, most frequently men. Splenomegaly and
capsular thinning increases the risk of rupture, which
may be due to minimal trauma, or occur spontaneously
]. Other causes of non-traumatic spontaneous splenic
rupture include haematological abnormalities such as
lymphoma and myelofibrosis, amyloidosis, and other
infections including malaria. Spontaneous splenic
rupture has a mortality of 12.2% [
], and may require urgent
surgical or radiological intervention. In the setting of
EBV infection estimates of mortality of spontaneous
splenic rupture are between 30 and 100% [
], and increased uptake in the spleen
seen on Positron emission tomography- computed
tomography (PET-CT) [
], has been described in primary
VZV infection. Macroscopic splenic nodularity is also
described in the setting of primary VZV infection [
However, there are only five reports of splenic rupture
occurring in the setting of primary VZV infection [
All cases are reported in young, adult males, as with our
]. In all cases, abdominal pain preceded the
onset of rash, and in all cases but one [
], there was no
haemodynamic compromise. The case we present is
consistent with these reports, with abdominal pain, likely
representing splenic rupture itself, preceding the rash by
48 h. Haemodynamic instability was not present, as with
four of the five published reports. Splenomegaly was
present as would be expected with a spontaneous splenic
rupture, although there is one case in the literature which
reported splenic rupture of a normal sized spleen [
There was no history of even minimal trauma, as with
Spontaneous splenic rupture is an unusual
complication of primary VZV infection. Here we report the sixth
known case in the literature. Splenic rupture should be
considered in cases of primary varicella in young adults
presenting with abdominal pain.
VZV: varicella zoster virus; HIV: human immunodeficiency virus; EBV: Epstein
Barr Virus; VCA: viral capsid antigen; EBNA: Epstein Barr Nuclear Antigen; CMV:
cytomegalovirus; PCR: polymerase chain reaction; HSV: herpes simplex virus;
PET-CT: positron emission tomography-computed tomography.
Both DH and AU were doctors within the medical team responsible for the
care of the patient. AU was responsible for data collection including patient
notes, lab results and imaging. AU wrote the case description. DH was also
responsible for the analysis and discussion within the case report. Both
authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Availability of data and materials
All results available included in figures and tables.
Consent for publication
Patient has given written consent for publication of information and images.
Ethics approval and consent to participate
There were no funding sources.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
1. Public Health England (PHE). The green book , Chapter 34 : Varicella. https ://www.gov.uk/government/publications/varicella-the -green-bookchapter-34. Accessed 13 Feb 2017 .
2. Centers for Disease Control and Prevention (CDC). The pink book , Chapter 22 : Varicella. https://www.cdc.gov/vaccines/pubs/pinkbook/varicella. html. Accessed 13 Feb 2017 .
3. Chapman AL , Watkin R , Ellis CJ . Abdominal pain in acute infectious mononucleosis . BMJ . 2002 ; 324 : 660 - 1 .
4. Schuler JG , Filtzer H . Spontaneous splenic rupture. The role of non-operative management . Arch Surg . 1995 ; 130 : 662 - 5 .
5. Renzulli P , Hostettler A , Schoepfer A , Gloor B , Candinas D. Systematic review of atraumatic splenic rupture . Br J Surg . 2009 ; 96 ( 10 ): 1114 - 21 .
6. Rothwell S , McAuley D . Spontaneous splenic rupture in infectious mononucleosis . Emerg Med . 2001 ; 13 : 364 - 6 .
7. Higgins PM . Splenomegaly in acute infections due to group A Streptococci and viruses . Epidemiol Infect . 1992 ; 109 : 199 - 209 .
8. Sheehy N , Israel DA . Acute varicella infection mimics recurrent Hodgkin's disease on F- 18 FDG PET/CT. Clin Nucl Med . 2007 ; 32 ( 10 ): 820 - 1 .
9. Tapp E. Ruptured spleen associated with chicken-pox . BMJ . 1969 ; 1 ( 5644 ): 617 - 8 .
10. Clifton LJ , Dhaliwal KS , Saif D , Mullerat P . Varicella zoster virus infection is an unusual case of splenic rupture . BMJ Case Rep . 2015 . https://doi. org/10.1136/bcr-2015-210909.
11. Ul Yaqin H. Spontaneous rupture of the spleen in the prodromal period of chickenpox . Postgrad Med J. 1969 ; 45 ( 519 ): 51 - 3 .
12. Vial I , Hamidou M , Coste-Burel M , Baron D. Abdominal pain in varicella: an unusual case of spontaneous splenic rupture . Eur J Emerg Med . 2004 ; 11 : 176 - 7 .
13. Harris RA , Boland SL . Varicella zoster associated with spontaneous splenic rupture . Aust N Z J Surg . 1998 ; 68 ( 2 ): 162 - 3 .