A 24-year-old woman from Haiti presented with abdominal pain and was initially investigated for acute cholecystitis, only to be diagnosed with disseminated herpes zoster and newly acquired HIV infection after surgical intervention, according to a clinical case report published in The Lancet Infectious Diseases (2026). The case illustrates how opportunistic infections can masquerade as common acute surgical emergencies, potentially delaying critical HIV diagnosis and treatment in resource-limited settings.
Key takeaways
- A 24-year-old Haitian patient presented with abdominal pain and mildly elevated liver enzymes (AST 70 U/L, ALT 33 U/L), initially attributed to acute cholecystitis
- Imaging findings of cholelithiasis and inguinal adenopathy led to cholecystectomy and lymph node biopsy on day 4 of admission
- Histopathology and serology ultimately revealed disseminated herpes zoster with acute hepatic necrosis and newly diagnosed HIV infection
- The case highlights the diagnostic challenge of distinguishing opportunistic infections from surgical emergencies in acutely ill patients
Clinical timeline and diagnostic progression
Days from presentation to diagnosis; illustrating diagnostic delay
Source: The Lancet Infectious Diseases case report, 2026 | Georgian Medical Journal News
Initial presentation masks underlying immunodeficiency
The patient presented to UnityPoint Health–Allen Memorial Hospital in Waterloo, Iowa with acute abdominal pain on day 1 of illness, according to the case report published in The Lancet Infectious Diseases (2026). Laboratory evaluation revealed mildly elevated aminotransferase levels: aspartate aminotransferase (AST) of 70 units per litre and alanine aminotransferase (ALT) of 33 units per litre, consistent with hepatic inflammation but not severe hepatocellular injury.
Abdominal and pelvic computed tomography imaging on day 2 or 3 demonstrated findings suggestive of cholelithiasis and bilateral inguinal adenopathy, with normal liver parenchyma on initial assessment. These imaging findings, combined with persistent pain, directed clinical suspicion toward biliary obstruction rather than infectious disease. The diagnostic anchoring bias toward surgical pathology reflected the prominent findings on imaging and the absence of constitutional symptoms typically associated with acute HIV infection in the initial presentation.
No mention of fever, rash, or systemic symptoms was documented at this early stage, making the underlying immunodeficiency clinically silent. This presentation pattern—isolated abdominal pain with imaging findings suggesting acute cholecystitis—exemplifies how opportunistic infections in newly acquired HIV can present as surgical emergencies.
Surgical investigation reveals unexpected pathology
Given persistent abdominal pain despite initial imaging, a hepatobiliary iminodiacetic acid (HIDA) scan was obtained on day 4, which suggested acute cholecystitis, prompting immediate surgical intervention. The clinical team performed a cholecystectomy and right inguinal lymph node excisional biopsy on the same day, according to the case documentation in The Lancet Infectious Diseases. This represented the critical diagnostic moment: tissue sampling, rather than intra-abdominal findings, ultimately revealed the true diagnosis.
Histopathological examination of the excised inguinal lymph node demonstrated varicella-zoster virus (VZV) infection, while the cholecystectomy specimen showed acute hepatic necrosis. Serological testing subsequently confirmed newly acquired HIV infection. The constellation of disseminated herpes zoster (manifest in the lymph node) combined with acute hepatic necrosis and newly diagnosed HIV represented a classic presentation of opportunistic infection in the setting of profound immunosuppression, though the clinical context—abdominal pain and imaging findings—had initially redirected diagnostic thinking toward non-infectious acute abdomen.
The timing of VZV reactivation in this case likely reflects advanced immunodeficiency (CD4 count not specified in the summary but presumed very low given the severity of disseminated disease and hepatic involvement). This raises questions about whether earlier HIV testing might have been warranted given the unusual constellation of findings.
Diagnostic lesson: HIV opportunistic infections can masquerade as surgical emergencies
This case demonstrates a critical diagnostic principle documented in clinical infectious disease literature: opportunistic infections in persons with untreated HIV often present with atypical or overlapping clinical features that can delay diagnosis. The CDC recommends HIV testing for all patients presenting with opportunistic infections, including disseminated varicella-zoster virus, regardless of epidemiological risk factors.
In resource-limited settings or areas with lower HIV prevalence awareness, this diagnostic challenge is amplified. The patient’s Haitian origin and young age without known medical comorbidities may have created false reassurance regarding HIV risk. Disseminated herpes zoster in immunocompetent individuals is rare; when present, it should prompt immediate HIV testing and consideration of other causes of severe immunosuppression (haematologic malignancy, severe immunosuppressive therapy).
For clinicians managing acute abdominal pain in young patients, particularly in populations with elevated HIV prevalence, the presence of adenopathy on imaging or elevated transaminases should lower the threshold for HIV testing. Early diagnosis would have prevented unnecessary surgery and accelerated initiation of antiretroviral therapy and opportunistic infection prophylaxis.
Public health implications in resource-constrained settings
Haiti faces significant HIV burden, with an estimated HIV prevalence of 1.6% among the adult population, according to WHO country epidemiological profiles. This case underscores the need for integration of HIV testing into acute care pathways, particularly in settings where late diagnosis is common and access to antiretroviral therapy is limited.
The delayed diagnosis in this case—requiring surgical intervention before infectious disease assessment—reflects a broader systems-level challenge: the siloing of surgical and infectious disease diagnostic pathways. Early HIV testing protocols, including rapid point-of-care testing in emergency departments and surgical wards in high-prevalence regions, could identify cases before invasive procedures are undertaken. This would reduce unnecessary morbidity, accelerate access to life-saving antiretroviral therapy, and enable preventive strategies for opportunistic infections.
A 24-year-old woman underwent cholecystectomy for presumed acute cholecystitis before tissue diagnosis revealed disseminated herpes zoster, acute hepatic necrosis, and newly acquired HIV infection—illustrating how opportunistic infections can masquerade as surgical emergencies and delay critical HIV diagnosis.
— Clinical case, The Lancet Infectious Diseases (2026)
What this means
Frequently asked questions
Why is disseminated herpes zoster a red flag for HIV?
Herpes zoster (shingles) in adults under 50 years, and especially disseminated VZV involving multiple dermatomes or extracutaneous sites, is a marker of immunodeficiency. According to medical literature on VZV epidemiology, disseminated zoster is rare in immunocompetent individuals and warrants immediate investigation for HIV, malignancy, or other causes of severe immunosuppression.
Could earlier HIV testing have prevented surgery?
Yes. If HIV testing had been performed as part of the initial workup—prompted by the constellation of abdominal pain, liver enzyme elevation, and adenopathy—the diagnosis would have been made before surgical intervention. CDC guidance recommends routine HIV testing for all adults aged 13–64 years in healthcare settings, regardless of risk factors, partly to prevent such diagnostic delays.
How does hepatic necrosis from VZV differ from acute hepatitis?
Varicella-zoster virus can cause direct hepatocellular necrosis in severely immunocompromised patients, manifesting as elevated transaminases and hepatic dysfunction. This is distinct from viral hepatitis (A, B, C) or autoimmune hepatitis. Histological examination—as performed in this case—is the definitive diagnostic method, as it demonstrates viral particles and inflammatory infiltration specific to VZV.
This case reinforces that even in the era of widely available HIV testing, diagnostic delays occur when opportunistic infections present with atypical clinical features or are anchored to alternative diagnoses. In regions with sustained HIV transmission, embedding HIV testing as a standard component of acute care pathways—rather than risk-based testing—could identify cases earlier and prevent unnecessary morbidity. Future improvement in clinical outcomes depends on greater integration of infectious disease assessment into acute surgical and medical emergency workflows.
Source: Disseminated herpes zoster with hepatic necrosis in a patient with newly diagnosed HIV, The Lancet Infectious Diseases, 2026
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