A rare case of varicella gangrenosum in adult

Varicella gangrenosum is a gangrenous ulceration of varicella lesions involving the skin and soft tissues of the body. It most commonly occurs in children less than 5 years of age and life threatening. This is a very rare complication of chicken pox in adults which deserves early diagnosis and management. 21-year-old male presented with blackish discoloration in the lateral aspect of right thigh for 5 days. He has positive history of chicken pox for his brother and sister following which he acquired it 15 days back. During that episode he had fever, headache and blisters which ruptured to heal by scab. But scab in right thigh coalesced to form the gangrenous area with serous discharge. On presentation he had no fever with local lesion and surrounding erythema. Patient underwent radical surgical debridement and regular dressing. Pus culture was sent which showed no growth. He gradually improved and the ulcer granulated well and split skin graft is done. Varicella gangrenosum is a life-threatening condition which can be either wet, moist or purpura fulminans. Patients who develop disseminated intravascular coagulation and have a grave prognosis. Surgical debridement is the only proven treatment which has led to better outcome. Only about 10 cases reported in literature so far regarding this condition.

The impact of varicella vaccination on varicella-related hospitalization rates: global data review / Impacto da vacina varicela nas taxas de internações relacionadas à varicela: revisão de dados mundiais

Abstract Objective: To describe the impact of varicella vaccination on varicella-related hospitalization rates in countries that implemented universal vaccination against the disease. Data source: We identified countries that implemented universal vaccination against varicella at the http://apps.who.int/immunization_monitoring/globalsummary/schedules site of the World Health Organization and selected articles in Pubmed describing the changes (pre/post-vaccination) in the varicella-related hospitalization rates in these countries, using the Keywords "varicella", "vaccination/vaccine" and "children" (or) "hospitalization". Publications in English published between January 1995 and May 2015 were included. Data synthesis: 24 countries with universal vaccination against varicella and 28 articles describing the impact of the vaccine on varicella-associated hospitalizations rates in seven countries were identified. The US had 81.4%–99.2% reduction in hospitalization rates in children younger than four years, 6–14 years after the onset of universal vaccination (1995), with vaccination coverage of 90%; Uruguay: 94% decrease (children aged 1–4 years) in six years, vaccination coverage of 90%; Canada: 93% decrease (age 1–4 years) in 10 years, coverage of 93%; Germany: 62.4% decrease (age 1–4 years) in 8 years, coverage of 78.2%; Australia: 76.8% decrease (age 1–4 years) in 5 years, coverage of 90%; Spain: 83.5% decrease (age <5 years) in four years, coverage of 77.2% and Italy 69.7%–73.8% decrease (general population), coverage of 60%–95%. Conclusions: The publications showed variations in the percentage of decrease in varicella-related hospitalization rates after universal vaccination in the assessed countries; the results probably depend on the time since the implementation of universal vaccination, differences in the studied age group, hospital admission criteria, vaccination coverage and strategy, which does not allow direct comparison between data.

Resumo Objetivo: Descrever o impacto da vacina varicela nas taxas de internações hospitalares associadas à varicela nos países que adotaram a vacinação universal contra a doença. Fontes de dados: Identificaram-se países que adotaram a vacinação universal contra varicela pelo site http://apps.who.int/immunization_monitoring/globalsummary/schedules da Organização Mundial de Saúde e selecionaram-se os artigos no Pubmed que descrevem a variação (pré/pós-vacinal) nas taxas de internações relacionadas à varicela desses países, com auxílio das palavras chaves: "varicella", "vaccination/vaccine" e "children" (ou) "hospitalization". Incluíram-se publicações em inglês entre janeiro de 1995 e maio de 2015. Síntese dos dados: Foram identificados 24 países com vacinação universal contra a varicela e 28 artigos que descrevem o impacto da vacina nas internações associadas à varicela em sete países. Os EUA tiveram 81,4%-99,2% de redução na taxa de internação em crianças menores de quatro anos, após 6-14 anos do início da vacinação universal (1995), com cobertura vacinal de 90%; Uruguai: 94% de queda (crianças de 1-4 anos) em 6 anos, cobertura vacinal de 90%; Canadá: 93% de redução (1-4 anos) em 10 anos, cobertura de 93%; Alemanha: 62,4% de redução (1-4 anos) em 8 anos, cobertura de 78,2%; Austrália: queda de 76,8% (1-4 anos) em 5 anos, cobertura de 90%; Espanha: 83,5% de queda (<5 anos) em 4 anos, cobertura de 77,2%; e Itália: queda entre 69,7%-73,8% (população geral), cobertura de 60%-95%. Conclusões: As publicações revelaram variação no percentual de queda na hospitalização por varicela após a vacinação universal nos países pesquisados; os resultados provavelmente dependem do tempo decorrido após introdução da vacinação universal, diferenças na faixa etária estudada, critérios de internação, cobertura vacinal e estratégia de vacina, não permitindo comparação direta entre os dados.

Severe Chicken Pox in an Immunocompromised Host after Chemotherapy / 계명의대학술지

Chicken pox is highly contagious and occurs most often in childhood. In normal children, systemic symptoms are usually mild and serious complications are rare. But in adults, especially in immunocompromised patients, it is more likely to be associated with life-threatening complications such as pneumonia, encephalitis and sepsis. A 38-year-old woman was admitted due to headache, fever and multiple umbilicated vesicles on face, trunk and both extremities for 3 days. She underwent chemotherapy for the breast cancer 20 days prior to admission. Based on typical clinical presentation and skin biopsy, she was diagnosed with chicken pox. Despite 5 days of intensive intravenous antiviral therapy (Acyclovir® 30 mg/kg/day), fever and headache continued and epigastric pain occurred. Finally, the patient was recovered from varicella after additional 7 days of antiviral therapy. Generally, old age or immunocompromised hosts have declined cellular immunity, so the incidence of chicken pox is higher and the clinical course is more severe. Herein, we report a case of chicken pox in the patient who underwent chemotherapy for breast cancer, requiring intensive treatment and close observation for systemic symptoms.

Scrub Typhus Co-infection in an Adolescent Girl with Varicella.

Background: Co-infections with scrub typhus have been described quite frequently in adults but less frequently in children. Case characteristics: An adolescent girl with varicella infection who had persistent fever. Associated clinical features like pain abdomen, vomiting, and features of third space losses made us suspect a co-infection. IgM and IgG antibodies by ELISA in acute and convalescent serum were suggestive of scrub typhus. Outcome: She recovered following a course of oral doxycycline. Message: In unexplained prolonged fever or atypical clinical manifestations not explainable by the primary disease process, coinfection needs to be considered.

Embarazo de gemelo acárdico coexistente con gemelo anencefálico, asociado a exposición a varicela en el primer trimestre: reporte de caso y revisión de la literatura / A case report and literature review regarding acardiac twin pregnancy coexisting with anencephalic twin, associated with being exposed to chicken pox during the first trimester of pregnancy

Introducción: el gemelo acárdico es una malformación congénita de muy baja prevalencia, 1 en 35.000 nacimientos, y se encuentra aproximadamente en 1 de cada 100 gemelos monocigóticos. La asociación de un gemelo acárdico con un segundo gemelo con malformaciones mayores ocurre aproximadamente en el 10% de los casos. El objetivo de este artículo es el reporte de un caso de muy baja prevalencia y la revisión de la literatura publicada sobre la etiología y fisiopatología asociada a la acardia, así como de las anomalías congénitas asociadas a esta y a la infección por virus de la varicela. Materiales y métodos: se presenta el caso de un embarazo gemelar monocoriónico biamniótico con un gemelo acardius mylacephalus y un segundo gemelo anencefálico, con exposición de la madre a varicela en el primer trimestre del embarazo. Se realizó cariotipo con bandas G, 46 XY sin anormalidades estructurales. Se hace una revisión de la literatura publicada en los últimos 10 años en las bases de datos PubMed, Ovid e HINARI. Conclusión: la importancia de este trabajo radica en que en la literatura revisada sólo se encontró un único reporte de la asociación de gemelo arcádico, coexistente con gemelo anencefálico. Además, sería el primer reporte de la relación entre esta combinación de malformaciones mayores en el embarazo gemelar y la exposición a varicela en el primer trimestre del embarazo.

Introduction: an acardiac twin is a congenital malformation having low prevalence (1 in 35,000) births and is found in about 1 in every 100 monozygotic twins. The association of an acardiac twin with a second twin having greater malformations occurs in around 10% of cases. This article was aimed at reporting a case having very low prevalence and a review of the literature published about the etiology and physiopathology associated with acardiac anomaly, as well as the congenital anomalies associated with it and infection by the chicken pox virus. Materials and methods: the case of monochorionicdiamniotic twin pregnancy involving an acardius mylacephalus twin and a second anencephalic twin is presented, the mother having been exposed to chicken pox during the first trimester of pregnancy. G-band kariotyping showed 46 XY having no structural abnormalities. A search was made of the literature published during the last 10 years in the PubMed, Ovid and HINARI databases. Conclusion: the importance of this report lies in the fact that only one report of the association of acardiac twin coexisting with anencephalic twin was found in the pertinent literature. This is also the first report of the relationship between this combination of greater malformations in twin pregnancy and exposure to chicken pox during the first trimester of pregnancy.

A Clinical Study of Chicken Pox in Adolescents and Adults / 대한피부과학회지

BACKGROUND: Chicken Pox, a highly contagious exanthem that occurs most frequently in childhood, is the result of primary infection with varicella zoster virus. Although it is generally a benign, self-limiting disease, varicella zoster virus infection may be associated with serious complications, especially in older adults. OBJECTIVE: The aim of this study was to elucidate the epidemiological and clinical characteristics and histopathologic features of varicella in adolescents and adults. METHOD: 57 patients who were admitted with varicella as adolescents or adults during a 20-year period from 1985 to 2004 were evaluated in regard to age, sex, monthly incidence, prodromal symptoms, and cutaneous manifestations. Patients were further assessed over abnormalities of laboratory tests, associated diseases, or histopathologic features. RESULTS: The results were as follows: 1. Varicella was seen most frequently in the 20~29 year-old group (47%), followed by the 10~19 year-old group (30%). The ratio of males to females was 1.36: 1. As a result of calculating the average age in five-year peroids from 1985 to 2004, the average age in the last period (2000-2004) was 29.2 +/- 7.0 years. This was found to be higher than in the other 5-year periods. 2. With regard to monthly occurrence, varicella was found to be most prevalant in May (21%). 3. The most common prodromal symptom was fever (74%), followed by a sore throat (32%) and headache (30%). 4. Common cutaneous manifestations of varicella were papules (84%), vesicles (79%) and typical umbilicated vesicles (65%). Pruritus (96%) was an extremely common symptom. 5. The most common laboratory abnormality was an abnormal liver function (28%). 6. Associated diseases of varicella were observed in 6 patients (10%). These included hepatitis or the hepatitis B virus carrier (5%), diabetes mellitus (2%), pulmonary tuberculosis (2%), and ulcerative colitis (2%). 7. Complications of varicella were 1 case (2%) of keratitis and 1 case (2%) of secondary infection. 8. In 7 cases of varicella stained with hematoxylin-eosin, all cases showed necrosis of keratinocytes and ballooning degeneration, and 5 cases had severe inflammatory infiltrations. Intra-epithelial vesicles were found in 6 cases, and multinucleated giant cells were found in 2 cases. CONCLUSION: The mean age of varicella patients showed an increase in the last 5-year period. In adolescents and adults with varicella, we recommend that patients should be evaluated for abnormalities of liver function.

A Clinical Study on Varicella zoster Virus Infection, Relating Factors and Treatment in Pediatric Cancer Patients

PURPOSE: We performed this study to contribute to the prevention and treatment of Varicella zoster virus infection in pediatric cancer patients through understanding of VZV infection, acyclovir efficacy and varicella vaccination. METHODS: A retrospective study was performed by reviewing chart from January 1988 to January 2001. RESULTS: The diseases among 19 cases were leukemia. 12 cases were solid tumors. Fourteen of leukemic patients were in maintenance chemotherapy, two in off chemotherapy, one in remission state, and two in the intensification when infected by VZV. There were 25 males and 6 females. The average age was 5.1 +/- 1.9 years in the chicken pox(CP) group and 6.5 +/- 3.1 years in the herpes zoster(HZ) group. The mean time of acyclovir treatment was 9.0 +/- 2.4 days and 9.4 +/- 2.9 days, respectively. Acyclovir was very effective. However, 2 patients showed slight increase of ALT/ AST. The HZ group had a more varicella infection history than the CP group. In the CP group, four patients had a history of varicella vaccination. In the HZ group, one patient of two who were without an infection history had a vaccination history. CONCLUSIONS: The most common therapeutic phase when infected was maintenance therapy. The prevalence of CP was higher in a lower age group than the HZ group and the mean time of acyclovir treatment was 9.2 days. All patients were cured. Despite a higher infection history in the HZ group, because of the history of varicella vaccination, we concluded that varicella vaccination can not prevent VZV infection. However, further investigation is necessary for the effect of vaccination on the manifestation.

Hemorrhagic Chicken Pox / 대한피부과학회지

Primary varicella infection usuelly runs a benign clinical course in the helthy population. However, hemorrhagic chicken pox presents with a very extensive eruption of hemorrhagic vesicles in patients with decreaed platelets or impaired immunity and is accompanied by severe constitutional symptoms. A 7-year-old male was admi due to abdompal pain for 1 day and peneralized vesicular eruption for 5 days. The eruption first appeared on the trunk and then spread to involved face, scalp and extrsmities. The skin rash was compatable with varicella but despite the administration of acclovir intravenously, the vesicular eruption became hemorrhagic. Ten days after admission, having experienced cardisc arrest twice and with his mental state in coms, he was diseharged as his situation was hopelesa. We have experienced a giatient diagnosed as having hemorrhagie, chicken pox complicated by encephalopathy.