Abstract: TH-PO1221
Presentation of Herpes Zoster as Knee Pain in a Pediatric Kidney Transplant Recipient
Session Information
- Pediatric Nephrology: CV Health, CKD, AKI, Dialysis, Transplantation, and Health Services Research
October 22, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Pediatric Nephrology
- 1800 Pediatric Nephrology
Authors
- Nguyen, Sophia T., ECU Health, Greenville, North Carolina, United States
- Davis, Nolan Michael, ECU Health, Greenville, North Carolina, United States
- Beng, Hostensia M., East Carolina University Brody School of Medicine, Greenville, North Carolina, United States
Introduction
Post-transplant infection remains a leading cause of hospitalization among pediatric kidney transplant recipients. While primary varicella is a well-recognized early complication, herpes zoster (HZ) is less commonly reported in children. In most cases, HZ is diagnosed through history and physical examination. However, immunosuppressed pediatric patients may present atypically and require a high index of suspicion. This case highlights an unusual presentation of HZ that occurred seven years after transplantation, manifesting initially only as knee pain.
Case Description
A 9-year-old male with end-stage renal disease secondary to obstructive uropathy requiring kidney transplantation presented to the emergency department with left knee pain and was ultimately diagnosed with HZ. Prior to transplantation, the patient received one dose of the varicella vaccine. His post-transplant course was complicated by antibody-mediated rejection and required escalation of his immunosuppressive therapy. Following treatment, he remained clinically stable until seven years after transplantation, when he developed worsening knee pain for six days. Initial lower extremity radiographs performed in the emergency department were unremarkable, and he was discharged with supportive care. However, his pain progressed and he was unable to bear weight or sleep, prompting admission for further evaluation and pain control. On day 7 of symptom onset, he developed a vesicular rash along the L3 dermatome. Viral culture demonstrated active varicella zoster virus (VZV) and his clinical presentation was consistent with localized shingles. He was treated with valacyclovir and reduction in immunosuppression, with subsequent improvement. Varicella antibodies obtained five months following treatment confirmed resolution of infection.
Discussion
Impaired cellular immunity is a predisposing factor in HZ infection. This case is a reminder that HZ should remain on the differential for pediatric renal transplant recipients presenting with unexplained neuropathic or dermatomal pain even years after transplantation to prevent delays in care. This patient’s history of antibody-mediated rejection and intensified immunosuppressive therapy predisposed him to developing an opportunistic infection. This case also demonstrates that VZV and HZ can still cause significant morbidity in pediatric kidney transplant patients despite immunization and treatment.