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Chickenpox in adult presenting as acute severe genital infection
CHICKENPOX IN ADULT PRESENTING AS ACUTE SEVERE GENITAL INFECTION ALEXANDER
S. CASS, M.B.B.S.
From the Division of Urology, Hennepin County Medical Center, Minneapolis, Minnesota
ABSTRACT-A case report of an acute severe genital infection simulating Four&&s gangrene was subsequently found to be caused by chickenpox.
Chickenpox is a disseminated disease with vesicular lesions on the trunk, face, and scalp. A male patient with severe genital infection is an unusual presentation of chickenpox. The more common causes of an acute erythematous scrotum are epididymoorchitis, torsion of the testis, trauma, Fournier’s gangrene, and urinary extravasation. The clinical features of a fever, a fine rash of papules, vesicles and pustules on the back and abdomen, normal testicles on palpation, and only the anterior scrotal wall involved with the acute erythematous lesion were the factors responsible for the decision that the scrotal lesion was most likely an early unusual manifestation of chickenpox rather than the other causes of an acute erythematous scrotum, especially Fournier’s gangrene. Case Report A fifty-one-year-old chronic alcoholic with secondary chronic hepatitis presented with a two-day history of scrotal pain and swelling with an itchy groin rash. Examination revealed a swollen red penis and scrotum with the appearance of early necrosis with exudate and a marked red rash on inner thigh (Fig. 1A). Only the anterior scrotal wall was involved, and the normal testes were readily palpated. A fine rash of papules, vesicles, and pustules was seen on the back and abdomen. A fever was present, and the patient was tremulous. Radiographs of the genital region showed no gas. Within three days the disseminated rash typical of chickenpox developed while genital swelling and redness improved (Fig. 1B). Treatment consisted of
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FIGURE1. (A) On admission, swelling of penis and scrotum with marked redness of scrotal skin suggestiue of Four&r’s cellulitis. (B) Three days after, reduced swelling bnd redness of penis and scrotum with disseminated lesions of chickenpox on abdomen and thighs; increased redness ofinner thigh due to secondary car&dial infection.
UROLOGY
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JANUARY 1993
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VOLUME 41, NUMBER 1
fever, hemorrhage into vesicles and surrounding skin, and secondary bacterial infection of the lesions can occur with cellulitis and erysipelas. The presence of a fine rash of papules, vesicles, and pustules on the back and abdomen with a high fever was suggestive of chickenpox. The genital lesion involved a swollen red penis and scrotum with the appearance of early necrosis with exudate and had the appearance of Fournier’s gangrene. However, only the anterior scrotal wall was involved in this process, both testicles were easily palpable, and radiographs of the genital region showed no gas. These were the factors responsible for the decision for the nonoperative management since it was thought that the scrotal lesion was an early unusual manifestation of chickenpox. The marked red rash on inner thigh was thought to be due to the wetness from the scrotal wall exudate aggravated by contact rubbing of the inner thighs. If the IV acyclovir and topical medications did not result in resolution of the scrotal lesion, then surgical management would have been considered. In the immunosuppressed patient there is a higher incidence of hemorrhage and progressive gangrenous lesions. Acyclovir is the least toxic antiviral drug effective in herpes simplex and in herpes zoster-varicella infections and can be beneficial with chickenpox when administered during the first five days of the disease. *
intravenous acyclovir and topical Burow’s compresses and triamcinolone ointment for the skin lesions. Comment Chickenpox is caused by the varicella-zoster virus. Fever and malaise begin when the rash appears. The first skin manifestations are pruritic maculopapules that evolve in a few hours to thin-walled vesicles which contain clear fluid and are surrounded by a red border. During the next day the erythema diminishes and the vesicles collapse in the center, forming umbihcated lesions which dry further and form scabs that fall off after several days without scarring. New maculopapules continue to erupt during the first three or four days of illness and go through a similar evolution. The rash is most concentrated on the trunk but pox are frequently seen on the face and scalp with lesser involvement of the extremities (centripetal) . Other causes of acute exanthems are measles (rubeola), rubella (German measles), and scarlet fever. The rash with measles is brick red, irregular, maculopapular, and spreads from the face to trunk to extremities. Koplik’s spots are present on the buccal mucosa. With rubella, a fine maculopapular rash of three days’ duration is present from the face to trunk to extremities, and posterior cervical and post auricular lymphadenopathy is also present. The rash with scarlet fever is generalized, punctate, and red and prominent on the neck, in the axilla, groin, and skinfolds. There is circumoral pallor, fine desquamation involving the hands and feet, and a strawberry tongue is present. Chickenpox is often more severe in adults than in children with more profuse rash, higher
UROLOGY
I
JANUARY
1993
I
VOLUME
41, NUMBER
701 Park Avenue South Minneapolis, Minnesota 55415 *Schroeder SA, Krupp MA, and Tierney LM (Eds): Current Medical Diagnosis and ‘lieatment, Norwalk, Connecticut, Lange, 1988, p 991.
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S. CASS, M.B.B.S.
From the Division of Urology, Hennepin County Medical Center, Minneapolis, Minnesota
ABSTRACT-A case report of an acute severe genital infection simulating Four&&s gangrene was subsequently found to be caused by chickenpox.
Chickenpox is a disseminated disease with vesicular lesions on the trunk, face, and scalp. A male patient with severe genital infection is an unusual presentation of chickenpox. The more common causes of an acute erythematous scrotum are epididymoorchitis, torsion of the testis, trauma, Fournier’s gangrene, and urinary extravasation. The clinical features of a fever, a fine rash of papules, vesicles and pustules on the back and abdomen, normal testicles on palpation, and only the anterior scrotal wall involved with the acute erythematous lesion were the factors responsible for the decision that the scrotal lesion was most likely an early unusual manifestation of chickenpox rather than the other causes of an acute erythematous scrotum, especially Fournier’s gangrene. Case Report A fifty-one-year-old chronic alcoholic with secondary chronic hepatitis presented with a two-day history of scrotal pain and swelling with an itchy groin rash. Examination revealed a swollen red penis and scrotum with the appearance of early necrosis with exudate and a marked red rash on inner thigh (Fig. 1A). Only the anterior scrotal wall was involved, and the normal testes were readily palpated. A fine rash of papules, vesicles, and pustules was seen on the back and abdomen. A fever was present, and the patient was tremulous. Radiographs of the genital region showed no gas. Within three days the disseminated rash typical of chickenpox developed while genital swelling and redness improved (Fig. 1B). Treatment consisted of
52
FIGURE1. (A) On admission, swelling of penis and scrotum with marked redness of scrotal skin suggestiue of Four&r’s cellulitis. (B) Three days after, reduced swelling bnd redness of penis and scrotum with disseminated lesions of chickenpox on abdomen and thighs; increased redness ofinner thigh due to secondary car&dial infection.
UROLOGY
!
JANUARY 1993
I
VOLUME 41, NUMBER 1
fever, hemorrhage into vesicles and surrounding skin, and secondary bacterial infection of the lesions can occur with cellulitis and erysipelas. The presence of a fine rash of papules, vesicles, and pustules on the back and abdomen with a high fever was suggestive of chickenpox. The genital lesion involved a swollen red penis and scrotum with the appearance of early necrosis with exudate and had the appearance of Fournier’s gangrene. However, only the anterior scrotal wall was involved in this process, both testicles were easily palpable, and radiographs of the genital region showed no gas. These were the factors responsible for the decision for the nonoperative management since it was thought that the scrotal lesion was an early unusual manifestation of chickenpox. The marked red rash on inner thigh was thought to be due to the wetness from the scrotal wall exudate aggravated by contact rubbing of the inner thighs. If the IV acyclovir and topical medications did not result in resolution of the scrotal lesion, then surgical management would have been considered. In the immunosuppressed patient there is a higher incidence of hemorrhage and progressive gangrenous lesions. Acyclovir is the least toxic antiviral drug effective in herpes simplex and in herpes zoster-varicella infections and can be beneficial with chickenpox when administered during the first five days of the disease. *
intravenous acyclovir and topical Burow’s compresses and triamcinolone ointment for the skin lesions. Comment Chickenpox is caused by the varicella-zoster virus. Fever and malaise begin when the rash appears. The first skin manifestations are pruritic maculopapules that evolve in a few hours to thin-walled vesicles which contain clear fluid and are surrounded by a red border. During the next day the erythema diminishes and the vesicles collapse in the center, forming umbihcated lesions which dry further and form scabs that fall off after several days without scarring. New maculopapules continue to erupt during the first three or four days of illness and go through a similar evolution. The rash is most concentrated on the trunk but pox are frequently seen on the face and scalp with lesser involvement of the extremities (centripetal) . Other causes of acute exanthems are measles (rubeola), rubella (German measles), and scarlet fever. The rash with measles is brick red, irregular, maculopapular, and spreads from the face to trunk to extremities. Koplik’s spots are present on the buccal mucosa. With rubella, a fine maculopapular rash of three days’ duration is present from the face to trunk to extremities, and posterior cervical and post auricular lymphadenopathy is also present. The rash with scarlet fever is generalized, punctate, and red and prominent on the neck, in the axilla, groin, and skinfolds. There is circumoral pallor, fine desquamation involving the hands and feet, and a strawberry tongue is present. Chickenpox is often more severe in adults than in children with more profuse rash, higher
UROLOGY
I
JANUARY
1993
I
VOLUME
41, NUMBER
701 Park Avenue South Minneapolis, Minnesota 55415 *Schroeder SA, Krupp MA, and Tierney LM (Eds): Current Medical Diagnosis and ‘lieatment, Norwalk, Connecticut, Lange, 1988, p 991.
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