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He was diagnosed in 2004 with alveolar haemorrhage and nephritic syndrome treated with corticoids and cyclophosphamide&#59; chronic kidney failure &#40;started haemodialysis in 2006&#41;&#59; pulmonary bleeding secondary to a disease flare that was treated with corticoids and cyclophosphamide in 2008&#59; and subsequent maintenance treatment with prednisone at 5mg&#47;day combined with sodium mycophenolate mofetil &#40;MMF&#41; at a dosage of 180mg&#47;12 hours&#46; This treatment is maintained to date&#46; Vesical transurethral resection in 2009 due to vesical neoplasm and atrial fibrillation&#46; His usual treatment was&#58; acetylsalicylic acid 100mg&#44; bisoprolol 2&#46;5mg&#47;24 hours&#44; omeprazole 20mg&#47;24 hours&#44; calcium carbonate 2&#46;5g&#47;24 hours&#44; dacortin 5mg&#47;24 hours and MMF 180mg&#47;24 hours&#46; He was administered Eprex 2000 and weekly Venofer during haemodialysis&#46;</p><p class="elsevierStylePara">He went to the emergency department with dyspnoea of several days of evolution&#44; coughing and slight expectoration&#44; together with abdominal pain that was variable in intensity&#46; He had nervous fever&#44; but no other symptoms of interest and was sent home&#46; He came to the emergency department again four days later&#44; being referred to our hospital&#46; He had the same clinical symptoms and in the physical examination presented with vesicular lesions limited to the abdomen on dermatomes D9&#44; D10 and D11&#44; which appeared two days later&#46; He had blood pressure of 80&#47;40mm&#160;Hg&#44; basal oxygen saturation of 84&#37;&#44; tachypnoea&#44; pain upon deep palpation in the right hypochondrium and intercostal muscle strain&#46; Wheezing could be noted on both sides until the middle fields during auscultation&#46; When he was admitted&#44; the biochemical and radiological data were&#58;</p><p class="elsevierStylePara">1&#46; &#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Haemoglobin &#40;Hb&#41;&#58; 11&#46;7g&#47;dl&#59; leukocytes&#58; 4200 &#40;N&#58; 91&#46;4&#37;&#44; L&#58; 5&#46;3&#37;&#41;&#59; platelets&#58; 77&#160;000&#46;</p><p class="elsevierStylePara">2&#46;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Aspartate transaminase &#40;GOT&#41;&#58; 6926IIU&#47;l&#59; alanine transaminase &#40;GPT&#41;&#58; 3587IIU&#47;l&#59; amylase&#58; 100IIU&#47;l&#59; lactate dehydrogenase &#40;LDH&#41;&#58; 1995IIU&#47;l&#59; creatine kinase &#40;CK&#41;&#58; 152IIU&#47;l&#59; myoglobin&#58; 708IIU&#47;l&#59; creatinine &#40;Cr&#41;&#58; 6&#46;3mg&#47;dl&#59; urea&#58; 88mg&#47;dl&#59; K&#58; 6nmol&#47;l&#59; Na&#58; 144mmol&#47;l&#59; total bilirubin&#58; 2&#46;17mg&#47;dl&#46;</p><p class="elsevierStylePara">3&#46; &#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; pH&#58; 7&#46;21&#59; CHO<span class="elsevierStyleInf">3</span>&#58; 12mEq&#47;l&#59; pCO<span class="elsevierStyleInf">2 </span>&#58; 32mm&#160;Hg&#59; pO<span class="elsevierStyleInf">2 </span>&#58; 59mm&#160;Hg&#46;</p><p class="elsevierStylePara">4&#46; &#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; International normalised ratio &#40;INR&#41;&#58; 1&#46;7&#59; prothrombin activity&#58; 37&#37;&#59; fibrinogen&#58; 663mg&#46;</p><p class="elsevierStylePara">5&#46; &#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Chest X-ray&#58; Bilateral interstitial and alveolar pattern with peripheral disposition and cotton-wool like distribution that does not improve following ultrafiltration &#40;Figure 1&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Given that the patient was immunocompromised&#44; and data supported liver failure and acute respiratory failure with skin conditions&#44; VZV was highly probable&#46; We decided to request a serology test for atypical cells&#59; it was VZV-positive&#44; so empirical treatment with acyclovir was started at a dosage of 250mg&#47;12 hours was started&#44; combined with antibiotic treatment &#40;levofloxacin 250mg&#47;48 hours plus cefotaxime 1g&#47;24 hours&#41;&#46; HZ diagnosis complicated with visceral dissemination was confirmed by polymerase chain reaction &#40;PCR&#41; for associated viral DNA&#44; and the remaining study was negative&#46; The patient progressed satisfactorily with acyclovir&#44; including clinical symptoms &#8211;recovery from respiratory failure and skin lesions&#8211;&#44; radiological symptoms&#44; &#8211;the interstitial and alveolar infiltration disappeared&#8211; and biochemical parameters &#40;Table 1&#41;&#46;</p><p class="elsevierStylePara">Complications secondary to VZV reactivation are common in immunocompromised patients&#46; Data collected from bone marrow transplant patients show that incidence varies from 17&#37; to 52&#37;&#44; according to different studies&#46;<span class="elsevierStyleSup">5&#44;9</span> For solid organ transplantation there is one retrospective study with a total of 869 patients worth mentioning&#44; which reports an incidence of 8&#46;6&#37;&#44; particularly in lung &#40;15&#46;1&#37;&#41; and kidney transplantation&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">Its clinical forms vary&#58; local zoster with or without visceral dissemination&#44; visceral involvement without skin lesion or generalised zoster with no visceral involvement&#46;<span class="elsevierStyleSup">1&#44;2</span> Reactivation takes place from the spinal ganglia&#59; its mechanism is still fairly unknown and presents as the main cause of all forms of HZV&#46; However&#44; there are contradictory data regarding cases secondary to reinfection in the literature&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">As in our case&#44; it can coexist with visceral dissemination&#46; Between 3&#37; and 15&#37; of HZ reoccur&#46;<span class="elsevierStyleSup">1&#44;3</span> It presents a high mortality rate&#44; with studies that show up to 55&#37;<span class="elsevierStyleSup">3</span> in cases secondary to complications such as meningoencephalitis&#44; pancreatitis or fulminant liver failure&#46;<span class="elsevierStyleSup">5</span> After skin&#44; the lung is the most affected organ&#44; followed by the liver&#46;<span class="elsevierStyleSup">1&#44;3</span> Diagnosis is hindered if the skin involvement does not presents before visceral dissemination&#44; as has been shown in a series of negative laparotomies in patients with significant abdominal pain&#46; Three of the 123 cases presented with symptoms of HZV&#46;<span class="elsevierStyleSup">7</span> Therefore&#44; it can present as variable clinical symptoms with a constitutional syndrome associated with symptoms of visceral involvement&#44; abdominal pain due to stretching of the Glisson capsule or pancreatitis&#44; respiratory failure&#44; etc&#46;&#44; which is often subsequently clearer&#44; once neuritis and vesicular exanthema &#8211;common HZ symptoms&#8211; develop&#46;</p><p class="elsevierStylePara">Diagnosis requires a high clinical suspicion in those patients with previous history of non-disseminated zoster and powerful immunosuppression&#46; Previous clinical background factors that must be highlighted are&#58; immunosuppression&#44; treatment with steroids and&#47;or MMF&#44; and previously positive serology&#46;<span class="elsevierStyleSup">3</span> We did not know the previous serology results for our patient&#44; but among his medical history we found significant immunosuppression due to the underlying condition&#44; in the last stage of MMF and steroid treatment&#44; which immunitary dysfunction caused by the very uraemic state added to&#46;</p><p class="elsevierStylePara">Diagnosis in immunocompromised patients or atypical symptoms can be confirmed by different laboratory techniques&#44; given that suspected clinical symptoms with positive serology may not be enough to confirm it&#46; Amplification of viral DNA in the blood or vesicular fluid in cases of visceral dissemination is quick&#44; has low contamination risk and is more sensitive than the conventional culture or direct immunofluorescence&#46;<span class="elsevierStyleSup">1&#44;6</span></p><p class="elsevierStylePara">In summary&#44; treatment should prevent complications&#46; Given the highly suspected clinical symptoms&#44; specific and early treatment is recommended&#46; Full dose acyclovir seems to be the most effective agent&#46; Treatment duration is still not defined in the literature and it should be combined with wide-spectrum antibiotic treatment to avoid complications due to over infection&#46;<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara">To conclude&#44; visceral dissemination of HZ is a complication of a variable frequency&#44; which has a high morbidity and mortality and requires rapid treatment management based on highly suspected clinical symptoms&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10826&#95;108&#95;21731&#95;en&#95;f1&#46;10826&#46;jpg" class="elsevierStyleCrossRefs"><img src="10826_108_21731_en_f1.10826.jpg" alt="Chest x-ray upon admission"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Chest x-ray upon admission</p><p class="elsevierStylePara"><a href="grande&#47;10826&#95;108&#95;21732&#95;en&#95;t1&#46;10826&#46;jpg" class="elsevierStyleCrossRefs"><img src="10826_108_21732_en_t1.10826.jpg" alt="Biochemical evolution"></img></a></p><p class="elsevierStylePara">Table 1&#46; Biochemical evolution</p>"
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