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CASE REPORT
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 143-145

Hemorrhagic varicella


Department of Dermatology Venereology & Leprology, Government General Hospital, Guntur, Andhra Pradesh, India

Date of Web Publication26-Mar-2018

Correspondence Address:
Bala Kumar Dorai
Government General Hospital, Guntur, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_24_17

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  Abstract 


Varicella is a benign disorder occurring commonly in children. Hemorrhagic varicella is a serious complication occurring in immunocompromised persons or those on immunosuppressive therapy. Our encounter with this case of Hemorrhagic varicella highlights that the rare hemorrhagic varicella can also occur in a chronic malnourished child. Prompt diagnosis and treatment with acyclovir leads to complete recovery.

Keywords: Acyclovir, chronic malnourished child, hemorrhagic varicella, immunocompromised


How to cite this article:
Nageswaramma S, Kumari G S, Dorai BK. Hemorrhagic varicella. Indian J Paediatr Dermatol 2018;19:143-5

How to cite this URL:
Nageswaramma S, Kumari G S, Dorai BK. Hemorrhagic varicella. Indian J Paediatr Dermatol [serial online] 2018 [cited 2020 Jan 29];19:143-5. Available from: http://www.ijpd.in/text.asp?2018/19/2/143/211810




  Introduction Top


Varicella is a self-limited disease caused by varicella-zoster virus (VZV). The virus causes two distinct form of disease, varicella (chicken pox) and herpes zoster (shingles), most common in children and adults, respectively. It is extremely contagious infection that occurs in epidemics among preschoolchildren and schoolchildren and is characterized by generalized vesicular rash.[1]

Once the infection occurs, it induces IgM, IgG, and IgA antibodies within 2–5 days after the appearance of rash, but they have incomplete protective effect. Cell-mediated immunity is more important, and when impaired, they are more chances of complications such as hemorrhagic chicken pox, encephalitis, pneumonitis, hepatitis, and thrombocytopenia and the mortality will be between 7% and 10%.


  Case Report Top


A male patient of age 15 years came to DVL OP of Government General Hospital, Guntur, with chief complaints of fluid-filled lesions over the skin for 15 days and bleeding from the skin lesions for 7 days.

The patient was apparently normal 15 days back and the present illness started as low-grade fever 15 days back. After one day, he developed fluid-filled lesions first over the forehead and then over the neck, upper chest, back, trunk, and lower limbs in the same order.

Small lesions subsided spontaneously after 7 days, but larger lesions ruptured leaving a raw surface. Bleeding from the lesions started 7 days after the lesions appeared.

One of the school friends had similar lesions as per his history, and he was not vaccinated with varicella vaccine in the childhood. There was no personal or family history of any significant disease in the past. The patient belonged to a poor social background.

On examination, the patient was afebrile at the time of presentation and general examination, vitals were normal except for pallor, and there was no any significant lymphadenopathy. His height was 140 cm and weight was 40 kg.

Cutaneous examination revealed multiple crusted hemorrhagic lesions over the face, trunk, chest [Figure 1], back [Figure 2], both upper limbs, and lower limbs [Figure 3] associated with mild tenderness. Few erosions were present over the trunk and upper limb associated with bleeding. Oral cavity, palms and soles, and genitals were normal.
Figure 1: Multiple crusted hemorrhagic lesions over the trunk and chest

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Figure 2: Multiple crusted hemorrhagic lesions over the back

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Figure 3: Hemorrhagic lesions over thigh

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Investigations revealed Hb - 7.2 g, white blood cell - 9500/mm 3, differential leukocyte count - P63, L27, M5, E5, erythrocyte sedimentation rate 65 mm/1 h, platelets - 3.9 lakhs/mm 3, packed cell volume - 25 ml%, serum proteins - 6.2 g%, albumin - 2.7 g%, globulin - 3.5 g%, random blood sugar - 84 mg%, blood urea - 16 mg%, serum creatinine 0.6 mg%, serum bilirubin 0.8 mg%, serum glutamic oxaloacetic transaminase - 17 IU/L, serum glutamic pyruvic transaminase - 16 IU/L, bleeding time - 1 min 35 s, clotting time - 3 min 50 s, P/S-microcytic hypochromic anemia, U/S abnormal, prothrombin time (PT) - 19 s, PT ratio - 1.3, PT-international normalized ratio - 1.5, activated partial thromboplastin time - 42 s, ASO titer - 1600 IU/ml, and varicella-zoster IgM - 2.45(positive - >1.1).

On the basis of clinical presentation and basic investigations, the diagnosis of hemorrhagic chicken pox was made, and the patient was started on tablet acyclovir 400 mg 4 times/day, antibiotics, and supportive therapy. The patient clinically improved and the bleeding stopped after 2 days of treatment [Figure 4], and after 1 week, the patient was discharged as the lesions completely healed.
Figure 4: Lesions after 2 days of treatment

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  Discussion Top


On an average, about 60 million cases of varicella occur worldwide each year, and the incidence in India is about 4.7 lakhs annually making it an inevitable disease of childhood. Varicella usually takes a benign course and the complications are usually mild, but in immunocompromised individuals and children, it takes a severe form.[2] Such persons are at risks of developing VZV infection of internal organs leading to pneumonia, hepatits, encephalitis, and disseminated intravascular coagulopathy.[3] They have an atypical presentation such as the lesions continue to erupt for more than 10 days; lesions appear on the palms and soles and may be hemorrhagic.

Hemorrhagic complications are common in immunocompromised or immunosuppressed populations. There have been case reports in which fatal hemorrhagic chicken pox occurred in steroid-dependent asthmatic patients,[4] nephrotic syndrome,[5] and chronic liver disease.[6],[7]

In our case, chronic malnutrition may lead to impaired cellular as well as to humoral immunity [8], and this may be the probable reason for hemorrhagic varicella.[9]

As uncomplicated cases are common in general population, it overshadows the morbidity and mortality associated with severe cases.[10] Children with complications of varicella requiring hospitalization are becoming more frequent than previously thought.[11] Even though a lethal outcome remains a rare occurrence, it may be of relevant concern while considering the overall incidence of chicken pox in general population.

Acyclovir which is lifesaving in such circumstances should be given as early as possible to be effective. Intravenous foscarnet may be given in patients not responding to acyclovir, but our patient responded well to oral acyclovir.

Chicken pox infection in immunocompromised patient should be treated promptly. Such patients should be advised to prevent contact with patients with chicken pox. If exposure occurs, intravenous immunoglobulins and acyclovir should be administered early. High-risk patients on exposure to varicella should be given varicella-zoster immunoglobulin, and this prevents or modifies the course of disease.[12] However, our patient responded well to oral acyclovir.

The present case tells the importance of varicella vaccination in the childhood to decrease varicella-related life-threatening complications.


  Conclusion Top


Our encounter with this case highlights that hemorrhagic varicella can also present in a child with chronic malnutrition. Prompt diagnosis and treatment with acyclovir leads to complete recovery. It also highlights the importance of health education among the people regarding varicella and the measures to be taken after exposure and strength the various nutrition programs available to the people.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gnann JW Jr. Varicella-zoster virus: Atypical presentations and unusual complications. J Infect Dis 2002;186 Suppl 1:S91-8.  Back to cited text no. 1
[PUBMED]    
2.
Kole AK, Roy R, Kole DC. An observational study of complications in chickenpox with special reference to unusual complications in an apex infectious disease hospital, Kolkata, India. J Postgrad Med 2013;59:93-7.  Back to cited text no. 2
  [Full text]  
3.
Public Health Foundation. Varicella. Epidemiology and Prevention of Vaccine Preventable Diseases (The Pink Book). 12th ed., Ch. 21. Public Health Foundation; May, 2012. p. 303-4. Available from: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/varicella.pdf. [Last accessed on 2013 Nov 05].  Back to cited text no. 3
    
4.
Morice AH, Lai WK. Fatal varicella zoster infection in a severe steroid dependent asthmatic patient receiving methotrexate. Thorax 1995;50:1221-2.  Back to cited text no. 4
[PUBMED]    
5.
Krebs RA, Burvant MU. Nephrotic syndrome in association with varicella. JAMA 1972;222:325-6.  Back to cited text no. 5
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6.
Xing T, Li L, Cao H, Huang J. Altered immune function of monocytes in different stages of patients with acute on chronic liver failure. Clin Exp Immunol 2007;147:184-8.  Back to cited text no. 6
[PUBMED]    
7.
Keeffe EB. Acute hepatitis A and B in patients with chronic liver disease: Prevention through vaccination. Am J Med 2005;118 Suppl 10A:21S-7S.  Back to cited text no. 7
[PUBMED]    
8.
Balfour HH Jr. Varicella zoster virus infections in immunocompromised hosts. A review of the natural history and management. Am J Med 1988;85:68-73.  Back to cited text no. 8
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9.
Moret Y, Schmid-Hempel P. Survival for immunity: The price of immune system activation for bumblebee workers. Science 2000;290:1166-8.  Back to cited text no. 9
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10.
Scrimshaw NS, SanGiovanni JP. Synergism of nutrition, infection, and immunity: An overview. Am J Clin Nutr 1997;66:464S-77S.  Back to cited text no. 10
[PUBMED]    
11.
Koturoglu G, Kurugöl Z, Cetin N, Hizarcioglu M, Vardar F, Helvaci M, et al. Complications of varicella in healthy children in Izmir, Turkey. Pediatr Int 2005;47:296-9.  Back to cited text no. 11
    
12.
Almuneef M, Memish ZA, Balkhy HH, Alotaibi B, Helmy M. Chickenpox complications in Saudi Arabia: Is it time for routine varicella vaccination? Int J Infect Dis 2006;10:156-61.  Back to cited text no. 12
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


This article has been cited by
1 MODERN FEATURES OF CHICKEN POX COURSE IN ADULTS
The Journal of V. N. Karazin Kharkiv National University, Series "Medicine". 2018; (36)
[Pubmed] | [DOI]



 

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