Disseminated herpes simplex virus (HSV) and varicella zoster virus (VZV) have been reported individually in immunosuppressed adults.We present a case of coinfection with disseminated HSV and VZV infection in a patient taking thalidomide for relapsed multiple myeloma. This is the first report of opportunistic infection associated with thalidomide. CASE REPORTThe patient was a 54-year-old female with a history of hypertension and multiple myeloma diagnosed in 1992, for which she received an autologous bone marrow transplant in 1995. In December of 1999, the patient developed a recurrence of her multiple myeloma, at which time she underwent sacral and left rib radiation therapy and was started on thalidomide therapy at 100 mg/day (which was increased to 200 mg/day 2 months later). She initially presented to an outside hospital with a generalized tonic-clonic seizure, was treated with phenytoin, and underwent a head computed tomography (CT) scan, which revealed a hemorrhage (1.0 by 0.5 cm) in the right putamen. She was immediately transferred to our hospital, where she was found to be obtunded with left-sided hemiparesis. A repeat head CT scan showed a hemorrhagic lesion (4.0 by 3.0 by 4.5 cm) in the right putamen/globus pallidus with slight mass effect and midline shift. Admission laboratory values were significant for a normal international normalized ratio (INR) and partial thromboplastin time (PTT) as well as a normal complete blood count. Liver function tests were not performed on admission, but those done approximately 1 month prior showed an aspartate aminotransferase (AST) level of 23 U/liter, an alanine aminotransferase (ALT) level of 32 U/liter, a total bilirubin level of 0.8 mg/dl, an alkaline phosphatase level of 70 U/liter, and a lactate dehydrogenase (LDH) level of 150 U/liter. She was given one dose of methylprednisolone at 125 mg, and after consultation with the neurosurgical service, conservative medical management was instituted with a nitroprusside drip to keep her systolic blood pressure below 145 mm Hg.The patient's mental status and neurologic examination were noted to wax and wane over the next few days, prompting two repeat head CT scans, which revealed only a mild increase in surrounding edema and midline shift, but no extension of the hemorrhage. No further steroid therapy was given for the cerebral edema, and she was treated with continued conservative management. The patient's platelet count was noted to gradually decrease to a minimum of 40,000/mm 3 , which was felt to be related to nitroprusside therapy. She was transfused a total of 48 U of single donor platelets (with two doses of hydrocortisone at 100 mg given with diphenhydramine and acetaminophen to prevent transfusion reaction), and the nitroprusside drip was discontinued with subsequent normalization of the platelet count.The patient showed some neurological and general improvement until late in the afternoon on the sixth day of hospitalization, when she complained of diffuse abdominal pain. On examination, the abdomen was noted ...