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A case is presented of cardiac arrhythmia associated with varicella zoster infection, affecting a 34‐year‐old man. The patient presented with episodes of seizure‐like activity, which were subsequently shown to be caused by ventricular fibrillation. The literature regarding this unusual complication of varicella zoster infection is discussed, as it affects both children and adults. Physicians who may face this condition, in accident and emergency, acute medicine, critical care medicine and infectious diseases, should all be aware of this serious complication.
Mr CP was a 34‐year‐old man who presented with a 5 day history of fever and generalised malaise, and a 24 h history of an erythematous, non‐pruritic rash. In the preceding 2 weeks his two children had contracted similar rashes diagnosed clinically as “chicken pox” (varicella zoster virus, VZV). On the day of presentation, the patient had suffered three episodes of self‐limiting, seizure‐like activity at home, witnessed by his wife, each lasting around 30 s, separated by several minutes. A fourth episode occurred on transferring to the ambulance. It was described as “grand mal” by ambulance staff, but was also associated with collapse and subsequent loss of carotid pulse. Cardiac monitoring revealed ventricular fibrillation, which was converted to sinus rhythm with one 200 J shock (fig 11).). On arrival at the accident and emergency department, his Glasgow Coma Score was 15 and he was cardiovascularly stable. Other than a widespread erythematous, vesicopapular rash covering his upper body, all other examination was normal.
Past medical history was unremarkable (with no history of varicella zoster), and he took no regular medications. He smoked 10–20 cigarettes per day with no excessive alcohol intake.
A presumptive diagnosis of VZV infection was made and high dose intravenous acyclovir was prescribed. Blood results showed a raised C‐reactive protein, potassium 3.1 mmol/l, calcium 2.19 mmol/l, magnesium 0.96 mmol/l and phosphate 0.98 mmol/l. Troponin T was 0.02 ng/ml on admission and later rose to 0.04 ng/ml, and the electrocardiogram (ECG) was unremarkable (fig 22).). Arterial blood gas was normal. Initial diagnosis was of possible varicella zoster‐associated encephalitis with seizures, with resultant hypoxia causing cardiac arrest, although subsequent computed tomographic scan and lumbar puncture were entirely normal.
Two further “fits” occurred shortly after admission. Cardiac monitoring during these events revealed ventricular tachycardia followed by asystole, which resolved spontaneously after 30 s, with agitation of the patient and thrashing of the limbs during this period. These episodes could indeed be mistaken by lay personnel for grand mal seizures, with subsequent mild disorientation lasting minutes only. Intravenous amiodarone infusion was commenced. The patient was transferred to the intensive care unit for cardiac monitoring and isolation, with a diagnosis of varicella myocarditis with associated ventricular arrhythmias. A subsequent echocardiogram was normal with good left ventricular function. Microbiology tests confirmed VZV on polymerase chain reaction (PCR) of skin, throat and nose swabs, but PCR of cerebrospinal fluid was negative for VZV.
The patient remained stable and was transferred to the cardiac care unit. He was discharged on a β‐blocker and aspirin, and remained well at follow‐up, with normal echocardiogram and 24 hour tape. He did not attend further follow‐up clinics and electrophysiological testing was not therefore performed.
Varicella zoster is a common disease with the majority of cases occurring in childhood. Prevalence of antibodies has been reported at >95% in over 30‐year‐olds, although there is felt to be an upward shift in the age distribution of cases from studies in the US and UK.1 Serious complications are rare and deaths are even rarer in the immunocompetent child, with the most common complications being encephalitis and pneumonia. Complications are more common in adults with VZV, particularly pneumonia. Varicella zoster was first recognised as a possible cause of myocarditis in 1953, based upon a study of seven necropsy findings.2
In infants, a case report in 19713 first demonstrated VZV myocarditis specifically affecting the conducting system of the heart (in an infant with multi‐organ involvement). This led to the suggestion that VZV myocarditis could lead to cardiac conduction disturbances, and supraventricular, and later ventricular, arrhythmias have been documented in infants with varicella zoster. Other subsequent complications of VZV myocarditis are thought to include the development of cardiomyopathy with subsequent heart failure.
In adults, VZV myocarditis with associated arrhythmias is less well documented. There is one case report4 of varicella with multi‐organ involvement where death was subsequently thought to be due to myocardial involvement with cardiomyopathy.
As far as we aware, this is the first documented case in the adult population of varicella zoster infection with demonstrated ventricular fibrillation, presumed secondary to myocarditis. This case presents further interest due to the initial confusion of the fibrillation episodes with seizures (as might be expected with VZV encephalitis). Ventricular fibrillation has been recognised to cause convulsive movements which may be confused with an epileptic seizure.
In summary, there is an increasing prevalence of varicella zoster infection presenting in adults. Complications are rare but can be serious. The possibility of myocarditis, often with associated rhythm disturbance, should be considered in patients with appropriate presentations. Acute physicians from all departments (emergency, acute medicine, intensive therapy unit) should therefore be aware of this potential complication.
Competing interests: None declared.
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