Disseminated visceral varicella presenting as gastric ulcers

Introduction: Herpes zoster results from reactivation of varicella-zoster virus (VZV) and classically presents with a dermatomal vesicular rash. Disseminated or visceral involvement is uncommon and predominantly occurs in immunosuppressed individuals. Gastrointestinal manifestations, such as oesophageal or gastric ulceration, are rare and can lead to diagnostic delay due to their non-specific presentation. Case description: We report the case of 70-year-old man presenting with progressive dysphagia and weight loss over four weeks. The symptoms were preceded by dermatomal facial vesicular lesions consistent with herpes zoster, followed by the appearance of non-dermatomal cutaneous lesions. The patient had underlying type 2 diabetes mellitus and was geriatric, constituting functional immunosuppression. Upper gastrointestinal endoscopy revealed multiple ulcerations in the oesophagus and gastric antrum. Histopathology examination demonstrated viral cytopathic changes compatible with VZV infection, supporting a diagnosis of disseminated visceral varicella. Due to limited antiviral availability, the patient was managed with supportive therapy, systemic corticosteroids and symptomatic treatment, resulting in significant clinical improvement and resolution of dysphagia. Conclusion: This case highlights disseminated visceral varicella as an important but under-recognised cause of gastrointestinal ulcerations in immunosuppressed elderly patients. Establishing standardised reporting criteria would allow for more persistent comparison and analysis of this rare manifestation of varicella infection. LEARNING POINTS: Disseminated varicella-zoster virus infection may involve the gastrointestinal tract and present as dysphagia or gastric ulcers in immunosuppressed patients.Elderly patients with diabetes mellitus are at increased risk for atypical and visceral manifestations of varicella-zoster virus, and increased risk of atypical or visceral varicella-zoster manifestations when gastrointestinal symptoms accompany recent or evolving skin lesions.While antiviral therapy is generally recommended for disseminated or visceral varicella-zoster infection, clinical improvement may occur with supportive care in selected cases. Nonetheless, close monitoring is mandatory and antivirals should be promptly initiated if clinical worsening is observed.