Adjunctive Varicella-Zoster Virus-Specific Immunoglobulin for Complicated Varicella-Zoster Virus Infection in Kidney Transplant Recipients: Case Series.

BACKGROUND

Kidney transplant recipients are at increased risk of severe varicella-zoster virus (VZV) infection due to chronic immunosuppression. While antiviral therapy is the mainstay of treatment, the role of adjunctive VZV-specific intravenous immunoglobulin (VZV-IVIG) in complicated disease remains insufficiently defined.

METHODS

We present a case series of 3 kidney transplant recipients with complicated VZV infection treated with VZV-IVIG in addition to standard antiviral therapy at a tertiary transplant center between 2024 and 2025. Clinical presentation, virological course, immunosuppression management, graft function, and outcomes were analyzed.

RESULTS

All patients were receiving maintenance immunosuppression and developed severe VZV manifestations, including disseminated primary infection with visceral and ocular involvement and herpes zoster with suspected ocular/visceral involvement. VZV-IVIG was administered as a single dose, short weekly course, or prolonged monthly therapy based on disease severity and virological response. Treatment was well tolerated, with no significant adverse events or deterioration in renal allograft function. Clinical stabilization and regression of cutaneous and systemic manifestations were observed in all cases. One patient with panuveitis and persistent viremia required repeated VZV-IVIG courses and achieved gradual virological suppression with prevention of further end-organ damage, although residual visual impairment remained.

CONCLUSIONS

Adjunctive VZV-IVIG may be a useful and safe therapeutic option in selected kidney transplant recipients with severe, refractory, or organ-threatening VZV infection, particularly in cases of persistent viremia or ocular involvement. Larger studies are needed to define optimal patient selection, dosing strategies, and treatment duration.