Rowland P, Wald E R, Mirro J R, Yunis E, Albo V C, Wollman M R, Blatt J
Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA 15213, USA.
J Clin Oncol. 1995 Jul;13(7):1697-703. doi: 10.1200/JCO.1995.13.7.1697.
Here we report the experience at the Children's Hospital of Pittsburgh (CHP) with varicella zoster virus (VZV) in children with acute lymphoblastic leukemia (ALL). This record review was prompted by a patient with ALL who died suddenly of varicella hepatitis within 24 hours of presentation with a single skin lesion.
We reviewed the medical records of children diagnosed with ALL at the CHP from January 1984 through December 1993, who subsequently developed VZV infection.
Of 294 patients aged 0 to 15 years, 41 (14%) were identified as having had 42 episodes of VZV infection. Twenty patients (49%) had received prophylaxis with varicella zoster immunoglobulin (VZIG), and all 39 patients in whom the diagnosis was made premortem were treated with acyclovir. Twenty-nine of the 42 cases (70%) had disease limited to the skin. Thirteen cases (30%) had extracutaneous involvement, and five of these episodes (12% of all cases) ended in death. Risk factors for progressive varicella included age greater than 6 years and intensive immunosuppressive therapy at the time of exposure. Six of eight patients with progressive varicella, including two who died, had received VZIG. The clinical presentation in 10 of 13 patients with progressive disease and in four of five patients who died was dominated by severe abdominal and/or back pain. In seven cases, these symptoms preceded the development of skin lesions by several days, and in six patients were associated with extensive involvement of the spleen by varicella, as demonstrated histopathologically by the presence of Howell-Jolly bodies on peripheral-blood smear or radiographically. No patient with uncomplicated varicella was reported to have had premonitory pain.
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.
在此我们报告匹兹堡儿童医院（CHP）对急性淋巴细胞白血病（ALL）患儿感染水痘带状疱疹病毒（VZV）的诊治经验。此次病例回顾是由一名ALL患儿引发的，该患儿在出现单个皮肤损害后24小时内突然死于水痘性肝炎。
我们回顾了1984年1月至1993年12月在CHP诊断为ALL且随后发生VZV感染的患儿的病历。
在294名0至15岁的患者中，41名（14%）被确定发生了42次VZV感染。20名患者（49%）接受了水痘带状疱疹免疫球蛋白（VZIG）预防治疗，所有39名生前确诊的患者均接受了阿昔洛韦治疗。42例病例中有29例（70%）疾病局限于皮肤。13例（30%）有皮肤外受累，其中5例（占所有病例的12%）死亡。水痘进展的危险因素包括年龄大于6岁以及接触时接受强化免疫抑制治疗。8例进展性水痘患者中有6例，包括2例死亡患者，接受了VZIG治疗。13例进展性疾病患者中的10例以及5例死亡患者中的4例的临床表现以严重腹痛和/或背痛为主。在7例中，这些症状在皮肤损害出现前数天出现，在6例患者中与水痘广泛累及脾脏有关，外周血涂片上出现豪-焦小体或影像学检查均证实了这一点。据报告，无并发症的水痘患者均未出现前驱性疼痛。
认识到这些前驱症状，即使在没有皮肤损害的情况下，甚至在有既往疾病史或接受过VZIG治疗的儿童中怀疑有水痘，都应促使采取早期诊断和治疗措施。
