Viral infections are an underrecognized problem in children on standard chemotherapy for acute lymphoblastic leukemia (ALL). In countries with high baseline seroprevalence of cytomegalovirus (CMV) such as India, it may be an important pathogen leading to fever, end-organ damage, and cytopenia. Data regarding the incidence and manifestations of CMV disease in pediatric ALL patients are scanty. The authors prospectively assessed all children on chemotherapy for ALL with prolonged febrile neutropenia (FN) for CMV disease over a 3-year period. Children with end-organ damage, including pneumonia, retinitis, and colitis, were also evaluated. Quantitative and qualitative polymerase chain reaction (PCR) from blood, body fluids, or tissue was done along with ophthalmologic evaluation. CMV disease was detected in 10% of the children with prolonged FN. In addition, other children were identified due to end-organ damage, lung and eye being the common organs of involvement. Time of CMV reactivation was essentially during nonintense phase of chemotherapy. Lymphopenia was present in most children, and prolonged lymphopenia was associated with relapse of CMV infection after therapy. The authors conclude that CMV is an important pathogen in children on standard chemotherapy for ALL. It has a good outcome with early detection and directed therapy. Parenteral ganciclovir is needed for a period of 14-21 days to prevent recurrence.

Anasarca as the presenting manifestation of juvenile dermatomyositis (JDMS) is extremely rare. We report a case of a 4-year-old boy who was initially managed for nephrotic syndrome in view of anasarca and mild hypoalbuminemia. Later, at presentation to our institute, a diagnosis of severe edematous JDMS was made in view of associated profound muscle weakness and characteristic skin changes. The child responded to aggressive immunosuppressive therapy. On further evaluation, he had evidence of acute parvovirus B19 infection. Our case illustrates anasarca as an uncommon severe manifestation of JDMS and the possible role of parvovirus B19 in the onset of this autoimmune disorder.