GENERALIZED ZOSTER IN A 16-YEAR-OLD AFTER BMT FOR LEUKEMIA

*R.F. Schumacher (1), E. Mazzolari (1), A. Chiodera (2), L.D. Notarangelo (1)
(1)Department of Pediatrics and (2)Infectious Diseases, University of Brescia, Brescia, Italy

Herpes Zoster (Shingles), characterized by crops of vesicles and neuralgic pain, is usually unilateral and confined to a dermatome. We here report on a 16-year-old, who had had Varicella in early childhood. At 14 years of age he was diagnosed with acute leukemia (T-ALL) and transplanted in second remission with bone marrow from his HLA-identical sister, who also had had Varicella as a child. He recovered well; prophylaxis with acyclovir and cotrimoxazole per os and IVIG every three weeks was continued for 12 months, until he had acceptable T and B cell function.
One year later he presented with severe, disabling pain in his right leg. He was seen by an orthopedist and, under suspicion of mono-neuralgia, also by a pediatric neuropsychiatrist who confirmed the diagnosis. His blood count at that time showed 4,200 leukocytes (25% lymphocytes) and 123,000 platelets. He was started on thiocolchicoside and an X-ray of his lower spinal column was planned for the next day. When he came back, pain persisted and red papules had erupted on his right thigh. Varicella Zoster was presumed (no varicella exposure had occurred) and given his medical history he was immediately isolated and started on Varicella Zoster VirusImmunoglobulin and acyclovir (1,500 mg/m2/day iv for 10 days). Nevertheless the next day the lesions had spread not only to the neighboring dermatomes but disseminated all over the body, including scalp and mucous membranes (fotos). WBC had decreased to 2,300 leukocytes (23% lymphocytes) and 76,000 platelets. In the following days there were no new eruptions and the disseminated lesions disappeared rapidly with the WBC turning normal. However, the lesions on his right leg required 2 weeks to heal. At the time the abstract is written he still suffers from paresthesia in his right thigh.
This case illustrates, that even with timely administration of VZVIG and acyclovir iv in post-BMT patients, Zoster may nonetheless disseminate and cause considerable direct (in our case approximately 10,000 US$) and indirect costs and - last but not least - pain!

Corresponding Author: R.F. Schumacher, MD, Department of Pediatrics, University of Brescia, Piazzale Spedali Civili 1, 25123 Brescia, Italy