Chicken Pox with Multisystem Complications

Abstract

Varicella zoster virus (VZV) infection is a common infection in children and adolescents. In most of the cases it is a self limiting disease without any complications. In Armed Forces this infection is important because troops stay in close proximity to each other, so there is increased chance of person to person spread. We present a case of chicken pox manifesting with multi-organ life threatening complications successfully managed at a peripheral hospital.

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*Graded Specialist (Medicine), HQ IMTRAT, C/o 99 APO. +Graded Specialist (Anaesthesia), 176 MH, C/o 56 APO. #DADH, HQ 16 Inf
Div, C/o 56 APO.
Received : 09.10.09; Accepted : 15.04.10 E-mail : nitinbajaj.76@gmail.com
Case Report
Introduction
Varicella zoster virus (VZV) infection is a common
infection in children and adolescents. In most of
the cases it is a self limiting disease without any
complications. In Armed Forces this infection is important
because troops stay in close proximity to each other, so
there is increased chance of person to person spread.
We present a case of chicken pox manifesting with
multi-organ life threatening complications successfully
managed at a peripheral hospital.
Case Report
A 34 year old male presented to the medical inspection
(MI) room with high grade, continuous fever of two days and
rash of one day duration. Rash started on the face and spread
over to the trunk and limbs. He was diagnosed as case of
chicken pox, isolated and started on oral acyclovir. After two
days, the patient developed increasing cough and dyspnoea
for which he was transferred to our hospital.
On arrival, he was severely dyspnoeic and unable to
maintain oxygen saturation in room air. He had tachycardia,
fever, a petechial rash all over the body and large
haemorrhagic bullae surrounded by an area of erythema,
centripetal in distribution (Fig. 1). Respiratory examination
revealed bilateral crackles all over lung fields. Examination of
other systems was unremarkable. Ryle’s tube aspirate
consisted of fresh blood and he had frank haematuria.
He was a smoker and there was history of household
contact with a case of chicken pox. He had a past history of
tubercular meningitis and was on anti tubercular drugs for
last 10 months. He had no known immunocompromised
disease and had not received steroids or immunosuppressive
drugs in the recent past.
Investigations showed thrombocytopenia, deranged liver
functions, renal functions and coagulopathy (Table1). Chest
radiograph revealed bilateral reticulo-nodular opacities with
sparing of apices (Fig. 2). Electrocardiograph (ECG) showed
sinus tachycardia. Arterial blood gas showed acute respiratory
acidosis with a pH of 7.21, pO2 of 50 mm of Hg, pCO2 of 76 mm
of Hg and HCO3 of 28 mEq/l.
A diagnosis of VZV infection with complications of
varicella pneumonia (VP) leading to adult respiratory distress
syndrome (ARDS), disseminated intravascular coagulation
(DIC) and hepatitis was made. The patient was ventilated
with lung protective strategy using a low tidal volume (TV)
of 6ml/kg and a high positive end expiratory pressure (PEEP)
of 10 cm of H2O. Controlled ventilation with paralysis and
sedation with vecuronium and propofol was administered to
the patient. Intravenous acyclovir in doses of 10 mg/kg 8th
hourly was instituted. Broad spectrum antibiotics meropenem
and teicloplanin were also added for possible bacterial
infection. Transfusion support with random donor platelets
(RDP), fresh frozen plasma (FFP) and whole blood were given
as patient had significant upper gastro intestinal (UGI) bleed
and haematuria.
In the first 48 hours of hospitalization he required 12 units
of RDP, 12 units of FFP and four units of whole blood
transfusion. He also developed oral, nasal and endotracheal
bleeding. Radiographic opacities increased by the second
day. PEEP and pressure support were increased to 15 cm of
H2O and TV decreased to 4 ml/kg. Steroids were added after
48 hours to counter ARDS. Varicella serology, sent after five
days of onset of rash, was positive (23 units/ml). Active
bleeding decreased after day three of hospitalization. His
Chicken Pox with Multisystem Complications
Maj N Bajaj*, Lt Col J Joshi+, Maj S Bajaj#
MJAFI 2010; 66 : 280-282
Key Words : Varicella zoster virus; Acute respiratory distress; Disseminated intravascular coagulation
Table 1
Investigation reports from first (D1) to eighth (D8) day of
admission
D1 D2 D3 D4 D5 D8
Hb 14.1 9.2 9.4 8.6 10.4 10.9
TLC 6100 12400 8800 9100 9600 9400
Platelet 20000 42000 94000 124000 140000 170000
S Bilirubin 5. 4 2. 6 1. 2 1. 4 1. 2 0. 9
ALT 130 76 39 44 44 42
AST 112 68 34 31 32 34
P T 13/48 13/40 13/26 13/20 13/18 13/15
Urea 5 7 50 42 3 7 32 3 2
Creatinine 1.3 1.2 1.0 0. 8 0.8 0.8
Na/K 124/6.2 135/4.0 145/3.8 142/3.4 140/3.5 138/3.6

MJAFI, Vol. 66, No. 3, 2010
Chicken Pox with Multisystem Complications 281
haematological parameters gradually improved and by third
day he did not require component support, however four
more units of whole blood were given over two days to replace
the blood loss. Biochemical parameters gradually normalized.
On day five patient developed bradycardia when heart
rate reduced to 40-50 beats per minute. ECG showed Mobitz
type 1, 2° heart block. Heart block reversed with atropine
bolus injection. Subsequently, over the next two days he
continued to have intermittent episodes of heart block, which
did not require any specific therapy. This transient ECG
change was attributed to myocarditis due to varicella infection.
Weaning trials were started by sixth day and he was
extubated by eighth day of hospitalization. Antibiotics and
acyclovir were continued for a total of ten days. Skin lesions
healed and chest radiograph also normalized by tenth day of
therapy (Fig. 3,4). ECG reverted back to normal. He was
discharged after he was restored to good health and all
laboratory data normalized.
Discussion
This patient when presented to our hospital, had fever
with rash. He had a large number of petechiae present
all over the body and haemorrhagic bullae, which had
characteristic distribution of a varicella rash. A diagnosis
of VZV infection with complications was considered
due to the characteristics of the rash.
VP is the commonest complication of VZV infections
in adults; its incidence has been estimated to be 2.3 in
400 cases [1]. Risk factors for VP are smoking, immuno-
compromised adults, severity of skin rash and chronic
obstructive lung disease [2]. Our patient was a smoker
and had a severe rash. Treatment of VP consists of
early institution of acyclovir therapy and aggressive
mechanical ventilation [3]. Acyclovir was started on
admission in this patient. The use of steroids has been
studied in a trial and has been found to significantly
reduce hospital and intensive care unit (ICU) stay and
moderately decrease mortality [4]. Respiratory acidosis
with hypercapnia in this patient was possibly because
of respiratory muscle fatigue as he was dyspnoeic for
more than 24 hours when he presented to us.
Haemorrhagic manifestations in varicella are a rare
Fig. 1 : Rash on trunk of patient depicting haemorrhagic bullae
and petechiae on body.
Fig. 2 : Chest radiograph of patient on admission showing
reticulonodular opacities in both lung fields.
Fig. 3 : Scab formation and healing of skin lesions prior to discharge
from hospital.
Fig. 4 : Chest radiograph after 10 days of therapy showing
radiological clearing.

MJAFI, Vol. 66, No. 3, 2010
282 Bajaj, Joshi and Bajaj
complication and not even a single case was seen in
two large case series of varicella related complications
[5,6]. In one case report, an immunocompetent male
with varicella infection with ARDS and DIC was
successfully managed with acyclovir, mechanical
ventilation, steroid pulse therapy hemofiltration and
component support [7]. Varicella serology is not routinely
used in uncomplicated cases, however in complicated
cases like these, where lesions of chicken pox do not
appear to be classic due to haemorrhagic manifestations,
this diagnostic test can be of great help. Immunoglobulin
M (IgM) in this patient was positive and confirmed our
diagnosis.
To conclude, this was a case of varicella infection
with severe, rare complications of DIC, ARDS,
myocarditis and hepatitis managed successfully with
acyclovir, mechanical ventilation and component support
at a peripheral hospital.
Conflicts of Interest
None identified
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Varicella Pneumonia. Chest 1998; 114: 426-31.
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Chicken pox complications in Saudi Arabia: Is it time for routine
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of varicella hospitalizations in the United States, 1995–2005.
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Journal Scan
Jason H Ko, Edward C Wang, David M Salve. Benjamin C
Paul, Gregory A Dumanian. Abdominal wall reconstruction.
Lessons learned from 200 “Components separation”
Procedures. Arch Surg 2009;144:1047-55.
The incidence of large incisional hernias is on the rise as more
and more damage control laparatomies are being performed for
abdominal trauma or intra-abdominal catastrophes. Over the time
the musculature of the abdominal wall retracts laterally and increases
the size of hernia. In addition there is a high incidence of fistula
formation in these cases. No consensus has been reached as to the
best method to deal with large midline abdominal wall hernias.
Repair of these hernias led to high recurrence rates, 43% for the
suture repair and 24% for the mesh repair. Component separation
technique is considered an ideal technique for large defects because
it loosens the contracted sides of abdominal wall to augment midline
repair and in addition this procedure leads to increased lateral
abdominal wall complication which may reverse lateral abdominal
wall atrophy. The mid line movement of tissue in component
separation permits the excision of all scarred and inflamed tissue,
decreasing the chance of recurrence.
This article describes the largest reported series of ventral hernia
repair by a modified components separation procedure for midline
abdominal hernias by a single surgeon at a single institution. This
was a retrospective study, studying the baseline characteristics
that affected the long term clinical outcomes including hernia
recurrences, major and minor complications. The study was
conducted over a period of 11 years during which 200 consecutive
patients were enrolled into the study. The study demonstrates
gradual evolution of the author’s technique starting with simple
component separation to use of acellular cadaveric dermis to augment
the repair to finally setting to augmentation of the repair with soft
polypropylene as the other methods did not give satisfactory
results. Of the 200 patients, in 79% cases primary components
separation was used, in 9% human a cellular cadaveric dermis
augmentation and in the remaining 12%, mesh underlay repair was
done. The study included 45.5% recurrent hernias. The cases were
followed up to 74 months with a mean follow up period of ten
months. The overall hernia recurrence rate was 21.5% in the study.
The mean time of recurrence for the overall series was 14.8 months.
The major complication occurred in 24% cases included hematoma,
infection that required drainage, myocardial infarction and death.
The uses of soft polypropylene in 9% logical regression analysis
was performed to predict the risk of hernia recurrence and
complications, elevated body mass index (BMI) demonstrated a
significant effect on hernia recurrence (odds ratio = 1.06, p = 0.08)
hernia width, diabetes mellitus, smoking and contamination had no
effect on hernia recurrence.
The study reinforces the fact that placement of mesh intra-
peritoneally will not increase the risk of adhesive bowel disease or
enterocutaneous fistulae. Out of 18 patients in whom mesh was
placed, none developed bowel obstruction, fistulae or experienced
mesh extrusion. Authors conclude that component separation
technique is an effective treatment choice for massive midline
hernias. Soft mid weight polypropylene mesh reinforcement of the
repair provides long term strength, durability and decreased
recurrence.
The technique seems applicable in most cases of massive midline
hernias, however it needs further evaluation as the number of cases
is small and follow up period of the technique is short.
Contributed by
Col PVR Mohan*
*Associate Professor (Dept of Surgery), AFMC, Pune-40.