Atypical recurrent varicella in 4 patients with hemopathies

Abstract

Relapsing varicella may occur in children with HIV infection and more rarely in younger adults. Our aim was to report unusual clinical, histologic, and virologic aspects of 4 elderly patients with malignant hemopathies who had an unusual form of recurrent varicella develop. Conventional microscopy, immunohistochemistry, and in situ hybridization were applied to smears and skin biopsy specimens. The patients presented a few dozen, scattered, large, papulovesicular lesions with central crusting. No zoster-associated pain or dermatomal distribution of the lesions was noted. Conventional microscopy revealed vascular changes and epidermal alterations typical for ␣-herpes virus infection. The varicella zoster virus major viral envelope glycoproteins gE and gB, and the immediate-early varicella zoster virus IE63 protein and the corresponding genome sequence for gE were detected on Tzanck smears; they were localized in endothelial cells and keratinocytes on skin biopsy specimens. The varicella zoster virus infection in endothelial cells, the vascular involvement, and the widespread distribution of the lesions suggest that the reported eruptions are vascular rather than neural in origin. These findings invalidate the diagnosis of herpes zoster but strongly support the diagnosis of recurrent varicella in an indolent and yet unreported presentation. Furthermore, these eruptions differ from relapsing varicella in children and young adults by the age of the patients, the paucity of clinical lesions, the larger diameter of the lesions and their peculiar clinical aspect, the significantly longer time interval between primary varicella and the recurrence, the prolonged healing time of the lesions, their mild disease course, and the fact that all the lesions are in the same stage of development. (J Am Acad Dermatol 2003;48:442-7.)

Chronic Herpes Zoster Duplex Bilateralis

“…Only in cases of severe immunosuppression, VZV can be reactivated in multiple dorsal root ganglias and conduct to multidermatomal HZ can be involved. The satellite lesions are probably of haematogenous origin (32). The HZ duplex persisted for more than 2 months and did not respond to aciclovir oral or intravenous therapy.…”

Recurrent Varicella in an Adult Psoriasis Patient Treated with Etanercept

“…As compared to classical chickenpox and relapsing varicella in children and young adults, disease manifestations were milder with fewer lesions (that all exhibited the same stage of development) [9] . Similar cases of 'breakthrough varicella' were also recently reported after immunization with a live attenuated varicella vaccine [11] .…”

“…Atypical recurrent varicella with disseminated lesions and without dermatomal clustering was described in immunocompromised patients with haemopathies and in paediatric renal transplant recipients treated with mycophenolate mofetil [9,10] . As compared to classical chickenpox and relapsing varicella in children and young adults, disease manifestations were milder with fewer lesions (that all exhibited the same stage of development) [9] .…”

Systemic varicella-zoster virus infection in two critically ill patients in an intensive care unit

“…It is often difficult to differentiate the one to the other. Although a report of seemingly apparent varicella in an adult exists [14], atypical recurrent varicella without characteristic clustering have been described in immunocompromised patients [15,16]. We assumed that the presenting cases were varicella, rather than zoster, because of the dermatological appearance: diffuse and bilaterally distributed, but not closely aggregated.…”

“…The vesicles or blisters are characteristic dermatological findings of VZV infection and can be the best indicator for diagnosis. However, VZV infection can progress without the appearance of typical vesicles, especially in immunocompromised patients [15,16]. In addition, specific antibodies are not always elevated in such patients [17,18].…”