Progressive varicella presenting with pain and minimal skin involvement in children with acute lymphoblastic leukemia.

Rowland, Paul; Wald, Ellen R.; Mırro, Joseph; Yunis, Eduardo J.; Albo, Vincent; Wollman, Michael R.; Blatt, Julie

doi:10.1200/jco.1995.13.7.1697

Cited by 53 publications

(57 citation statements)

References 12 publications

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“…This is consistent with previous reports (totaling 31 patients who died after similar presentations) that abdominal and/or back pain, often preceding the appearance of skin lesions, is an ominous sign and portends a severe course. 5,20,21 Thus, in an immunocompromised patient with unexplained back or abdominal pain, the early empiric use of acyclovir should be considered, even in the absence of other symptoms or signs of varicella. Both patients in this report first developed vesicles in the genital area, highlighting the need for a thorough skin examination in the febrile immunocompromised patient.…”

Section: Discussionmentioning

confidence: 99%

Recent Steroid Therapy Increases Severity of Varicella Infections in Children With Acute Lymphoblastic Leukemia

et al. 2005

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ABSTRACT. Objective. The varicella-zoster virus (VZV) continues to be a dangerous pathogen to immunocompromised children. Children with acute lymphoblastic leukemia (ALL) are treated with intermittent steroid therapy. This study was undertaken to examine the relationship between steroid therapy for ALL and severity of varicella infection.Methods. We performed a retrospective review of patients who were on Pediatric Oncology Group Protocol 9201 and had a history of varicella infection. Pediatric Oncology Group 9201 is a phase III study for the treatment of children with lesser risk ALL diagnosed between 1992 and 1999. Cases of varicella were coded 1 to 5 on the basis of severity: grade 1 caused minimal to no symptoms, grade 2 caused mild to moderate symptoms that did not require hospitalization, grade 3 caused symptoms severe enough to require hospitalization and intravenous acyclovir, grade 4 caused severe disease that had complications or that required intensive care, and grade 5 resulted in death.Results. Of 697 enrolled patients, 110 (15.8%) developed primary varicella; 59% of these were male. For analysis, disease grade was dichotomized into nonsevere (grades 1 and 2) and severe (grades 3, 4, and 5). Of the 110 patients, 56 had nonsevere disease; 54 had severe disease, including 2 deaths. Of the patients whose varicella was diagnosed within 3 weeks of receipt of prednisone, 70% had severe infection, whereas only 44% of those who had not received prednisone within 3 weeks had severe infection. The odds ratio for having a severe infection within 3 weeks of prednisone versus >3 weeks is 2.9 (95% confidence interval: 1.1-7.9). By multivariate analysis, older age at ALL diagnosis, years from ALL diagnosis to VZV diagnosis, and VZV diagnosis within the 4-week period of interest (during or within 3 weeks of prednisone therapy) all were independently associated with an increased risk for severe infection.Conclusions. This study represents the largest study to date of varicella in children with ALL and provides convincing evidence that prednisone therapy during the VZV incubation period significantly increases the risk for developing severe varicella infection. In addition, older age is associated with more severe infection. Despite the varicella vaccine and a dropping incidence of primary infections, VZV remains a dangerous pathogen for pediatric patients with ALL. With the possible exception of induction therapy, patients who are on ALL therapy and are exposed to varicella should have steroid therapy delayed until after the VZV incubation period. T he varicella-zoster virus (VZV) is well recognized as a potential cause of morbidity and mortality in immunocompromised children. Small series and case reports in children have noted an association between steroid therapy and severe VZV infections. [1][2][3][4][5][6][7][8] In children with acute lymphoblastic leukemia (ALL), steroid therapy and its relation to VZV severity have not been well studied. We hypothesized that patients who received recent (within 3 weeks) ster...

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Section: Discussionmentioning

confidence: 99%

Recent Steroid Therapy Increases Severity of Varicella Infections in Children With Acute Lymphoblastic Leukemia

et al. 2005

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“…In contrast, the detection of VZV DNA in peripheral blood by PCR has been more recently recommended in patients with no rash but suspicion of VZV infection. 5,18 Finally, it is important to emphasize again the possible connection between abdominal pain and VZV infection in immunocompromised patients. Because the infection in these patients carries a significant risk of mortality, antiviral treatment with acyclovir should be instituted as soon as other causes are excluded.…”

Section: Discussionmentioning

confidence: 99%

“…Four of seven patients died. 5 Immune reconstitution takes about 12 months after bone marrow transplantation 6,7 and is further delayed in allogeneic transplant recipients with chronic GVHD receiving immunosuppressive treatment. In a retrospective analysis of 236 children transplanted with autologous marrow, 54 (23%) patients experienced at least one episode of VZV infection at a median of 83 days (range 25-225 days) after the first transplant, and at a median of 52 days (range 4-133) after the second ABMT.…”

Section: Discussionmentioning

confidence: 99%

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Inappropriate antidiuretic hormone secretion, abdominal pain and disseminated varicella-zoster virus infection: an unusual triad in a patient 6 months post mini-allogeneic peripheral stem cell transplant for chronic myeloid leukemia

Szabó

Horvath

Seimon

et al. 2000

Bone Marrow Transplant

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Summary:Severe abdominal pain followed by inappropriate antidiuretic hormone secretion (SIADH) preceding by several days the skin manifestation of varicella-zoster virus (VZV) infection in an immunocompromised patient is described. This is a rare presentation of a severe infection described previously only once in a chronic myeloid leukemia (CML) patient 5 months post allo-BMT during immunosuppressive treatment with cyclosporin A. This is the first case described in the setting of nonmyeloablative preparation with fludarabine and melphalan and followed by donor leukocyte infusion (DLI) 2 and 4 months post allo-BMT. The influence of these factors on development of VZV virus infection is discussed. We also highlight the high incidence and high mortality in VZV infection in immunocompromised patients as well as the frequent atypical presentation. Bone Marrow Transplantation (2000) 26, 231-233. Keywords: inappropriate antidiuretic hormone secretion; varicella-zoster virus infection; abdominal pain; bone marrow transplantation Case reportA 57-year-old man was admitted to Royal Adelaide Hospital with a 2 day history of severe abdominal pain accompanied by nausea, vomiting and constipation. The patient had received an allogeneic peripheral blood stem cell transplant for CML 6 months prior to this admission and had been prepared with a non-myeloablative protocol. A combination of fludarabine 30 mg/m 2 i.v. for 5 days (days −6 to −2) and melphalan 140 mg/m 2 on day −1 was used as preparation before the transplant. Therefore, donor leukocytes were infused at 2 and 4 months post transplant (3 × 10 6 CD3 + cells/kg and 1 × 10 7 CD3 + cells/kg, respectively) according to the protocol. The patient did not develop GVHD. He was well until the day of admission, when suddenly, severe abdominal pain developed in association with nausea, vomiting and constipation.On admission the patient was afebrile, the abdomen was distended and tender and bowel sounds were diminished. The liver and spleen were not palpable. Liver function tests, serum amylase and serum lipase were within normal ranges. Plain abdominal X-ray showed dilated large bowel and some air-fluid levels in the small bowel, compatible with ileus. A gastrograffin enema excluded bowel obstruction. Glycerine and oil enema resulted in a small quantity of stool being passed but only temporary improvement in the pain. On day 2 after admission it was noted that the serum sodium (seNa) and plasma osmolality (plOsm), having initially been normal, had both declined, to 120 mmol/l (normal range 137-145) and 243 mmol/l (normal range 265-285), respectively. Urine showed an increased sodium concentration (urNa), up to 164 mmol/l (significant above 40 mmol/l) and increased osmolality to 813 mosmol/l (significant above 300 mosmol/l). Blood pressure was elevated to 180/110. Thyroid and adrenal tests were within normal limits. Given these results a diagnosis of inappropriate antidiuretic hormone secretion (SIADH) was made. Fluid restriction was instituted (1000 ml a day) with slight improvem...

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“…En niños con cáncer, la infección por VVZ puede producir una enfermedad grave 2 , debido a la disfunción de la inmunidad provocada por la enfermedad de base y/o el tratamiento con fármacos antineoplásicos o corticoesteroidales [3][4][5] .…”

Section: Introductionunclassified

Seroprevalencia de virus varicela-zoster en niños con cáncer en seis hospitales de Santiago, Chile

Izquierdo

Zubieta²,

G³

et al. 2012

Rev. chil. infectol.

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Progressive varicella presenting with pain and minimal skin involvement in children with acute lymphoblastic leukemia.

Abstract: Recognition of these prodromes and suspicion of varicella even in the absence of skin lesions and even in children with a history of prior disease or VZIG administration should prompt early diagnostic and therapeutic measures.

Cited by 53 publications

References 12 publications

Recent Steroid Therapy Increases Severity of Varicella Infections in Children With Acute Lymphoblastic Leukemia

Recent Steroid Therapy Increases Severity of Varicella Infections in Children With Acute Lymphoblastic Leukemia

Inappropriate antidiuretic hormone secretion, abdominal pain and disseminated varicella-zoster virus infection: an unusual triad in a patient 6 months post mini-allogeneic peripheral stem cell transplant for chronic myeloid leukemia

Seroprevalencia de virus varicela-zoster en niños con cáncer en seis hospitales de Santiago, Chile

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