Varicella Zoster Virus-Induced Complete Heart Block

A 60-year-old man with atrial fibrillation, diabetes, and postrenal transplant status on immunosuppressive therapy complained of a painful rash on his abdomen, generalized weakness, and lightheadedness over the past 2 weeks. Blood pressure was 128/44 mm Hg and heart rate 25 beats per minute. On physical examination, he had dermatomal rash extending across his left abdomen, flank, and back that did not cross midline (Figure 1). A 12-lead electrocardiogram showed atrial fibrillation with complete heart block (Figure 2). An echocardiogram revealed normal left ventricular ejection fraction of 65% with no regional wall abnormalities, troponin levels were normal, and there were no metabolic abnormalities. He underwent placement of a permanent pacemaker. Two days later, he became acutely encephalopathic. An infectious workup was initiated, including obtaining cultures from the skin lesions and the cerebrospinal fluid obtained at the time of a lumbar puncture. Cultures from both the skin lesions and the cerebrospinal fluid were positive for varicella zoster virus. Intravenous acyclovir was initiated with improvement in mental status, but the complete heart block remained …