Severe hepatitis associated with varicella zoster virus infection in a patient with diffuse large B cell lymphoma treated with rituximab-CHOP chemotherapy
First Online: 18 August 2012 Received: 11 May 2012 Revised: 21 July 2012 Accepted: 30 July 2012 DOI:
10.1007/s12185-012-1160-4 Cite this article as: Okamoto, A., Abe, A., Okamoto, M. et al. Int J Hematol (2012) 96: 516. doi:10.1007/s12185-012-1160-4 Abstract
Severe disseminated varicella zoster virus (VZV) infection rarely occurs in patients who are not recipients of hematopoietic stem cell transplantation. This report concerns severe disseminated VZV infection in a diffuse large B cell lymphoma (DLBCL) patient treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP). The patient was an 82-year-old male with DLBCL who had a history of type II diabetes mellitus. He incurred VZV infection with severe hepatitis and disseminated intravascular coagulopathy after three courses of R-CHOP. When the VZV infection occurred, anti-VZV IgG was not detected and lymphopenia was observed. We initiated treatment with acyclovir, immunoglobulin, and thrombomodulin alpha, and rescued this patient. We suggest that the use of chemotherapy for immune-suppressed elderly lymphoma patients may involve the risk of severe VZV infection.
Keywords Varicella zoster virus Rituximab Hepatitis Disseminated intravascular coagulopathy References
Ennishi D, Terui Y, Yokoyama M, et al. Increased incidence of interstitial pneumonia by CHOP combined with rituximab. Int J Hematol. 2008;87:393–7.
Katsuya H, Suzumiya J, Sasaki H, et al. Addition of rituximab to cyclophosphamide, doxorubicin, vincristine, and prednisolone therapy has a high risk of developing interstitial pneumonia in patients with non-Hodgkin lymphoma. Leuk Lymphoma. 2009;50:1818–23.
Coiffier B, Lepage E, Briere J, et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med. 2002;346:235–42.
Habermann TM, Weller EA, Morrison VA, et al. Rituximab-CHOP versus CHOP alone or with maintenance rituximab in older patients with diffuse large B-cell lymphoma. J Clin Oncol. 2006;24:3121–7.
Pfreundschuh M, Schubert J, Ziepert M, et al. Six versus eight cycles of bi-weekly CHOP-14 with or without rituximab in elderly patients with aggressive CD20+ B-cell lymphomas: a randomised controlled trial (RICOVER-60). Lancet Oncol. 2008;9:105–16.
Pfreundschuh M, Trumper L, Osterborg A, et al. CHOP-like chemotherapy plus rituximab versus CHOP-like chemotherapy alone in young patients with good-prognosis diffuse large-B-cell lymphoma: a randomised controlled trial by the MabThera International Trial (MInT) Group. Lancet Oncol. 2006;7:379–91.
Aksoy S, Dizdar O, Hayran M, Harputluoglu H. Infectious complications of rituximab in patients with lymphoma during maintenance therapy: a systematic review and meta-analysis. Leuk Lymphoma. 2009;50:357–65.
Gea-Banacloche JC. Rituximab-associated infections. Semin Hematol. 2010;47:187–98.
Mizoguchi F, Nakamura S, Iwai H, Kubota T, Miyasaka N. Varicella-zoster virus hepatitis in polymyositis. Mod Rheumatol. 2008;18:301–5.
Alvite-Canosa M, Paniagua-Martin MJ, Quintela-Fandino J, Otero A, Crespo-Leiro MG. Fulminant hepatic failure due to varicella zoster in a heart transplant patient: successful liver transplant. J Heart Lung Transplant. 2009;28:1215–6.
Bermudez A, Marco F, Conde E, Mazo E, Recio M, Zubizarreta A. Fatal visceral varicella-zoster infection following rituximab and chemotherapy treatment in a patient with follicular lymphoma. Haematologica. 2000;85:894–5.
Leena M, Ville V, Veli-Jukka A. Visceral varicella zoster virus infection after stem cell transplantation: a possible cause of severe abdominal pain. Scand J Gastroenterol. 2006;41:242–4.
Koc Y, Miller KB, Schenkein DP, et al. Varicella zoster virus infections following allogeneic bone marrow transplantation: frequency, risk factors, and clinical outcome. Biol Blood Marrow Transplant. 2000;6:44–9.
Kimura H, Kido S, Ozaki T, et al. Comparison of quantitations of viral load in varicella and zoster. J Clin Microbiol. 2000;38:2447–9.
Roque-Afonso AM, Bralet MP, Ichai P, et al. Chickenpox-associated fulminant hepatitis that led to liver transplantation in a 63-year-old woman. Liver Transpl. 2008;14:1309–12.
Aksoy S, Harputluoglu H, Kilickap S, et al. Rituximab-related viral infections in lymphoma patients. Leuk Lymphoma. 2007;48:1307–12.
Heininger U, Seward JF. Varicella. Lancet. 2006;368:1365–76.
Arvin AM. Immune responses to varicella-zoster virus. Infect Dis Clin North Am. 1996;10:529–70.
Weinberg A, Lazar AA, Zerbe GO, et al. Influence of age and nature of primary infection on varicella-zoster virus-specific cell-mediated immune responses. J Infect Dis. 2010;201:1024–30.
Hata A, Kuniyoshi M, Ohkusa Y. Risk of Herpes zoster in patients with underlying diseases: a retrospective hospital-based cohort study. Infection. 2011;39:537–44.
Loparev VN, Argaw T, Krause PR, Takayama M, Schmid DS. Improved identification and differentiation of varicella-zoster virus (VZV) wild-type strains and an attenuated varicella vaccine strain using a VZV open reading frame 62-based PCR. J Clin Microbiol. 2000;38:3156–60.
Hardy I, Gershon AA, Steinberg SP, LaRussa P. The incidence of zoster after immunization with live attenuated varicella vaccine. A study in children with leukemia. Varicella Vaccine Collaborative Study Group. N Engl J Med. 1991;325:1545–50.
Arvin AM. Varicella-zoster virus. Clin Microbiol Rev. 1996;9:361–81.
de Jong MD, Weel JF, van Oers MH, Boom R, Wertheim-van Dillen PM. Molecular diagnosis of visceral herpes zoster. Lancet. 2001;357:2101–2.
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