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Varicella complicated by group A streptococcal facial cellulitis
770 Brief reports
J AM ACAD DERMATOL NOVEMBER 2001
Varicella complicated by group A streptococcal facial cellulitis J. Santos-Juanes,a A. Medina,b A. Concha,b C. Galache,a J. Sánchez del Río,a and C. Reyb Oviedo, Spain An increase has been recently noted in the incidence of life-threatening group A β-hemolytic streptococcal (GABHS) infections in children recovering from varicella. We report our experience with a patient who required pediatric intensive care unit admission because of a serious GABHS infection 1 week after the onset of varicella. Emergency physicians must look for this complication in patients with varicella remaining abnormally febrile and presenting unusual manifestations. (J Am Acad Dermatol 2001;45:770-2.)
V
aricella is usually a benign and self-limited disease manifested by mild systemic symptoms, characteristic rash, and low-grade fever.1 In Asturias, the incidence of varicella is 476.8 per 100,000 population. Serious problems related to varicella in the immunocompetent patient are relatively rare, although minor complications are common. Bacterial infections, which are facilitated by disruption of the skin barrier and possibly by transient virus-induced alterations of the immune functions, are prominent among the complications of varicella in normal children. Group A β-hemolytic streptococcus (GABHS) and Staphylococcus aureus are the
From the Service of Dermatology II,a and the Pediatric Intensive Care Unit,b Department of Pediatrics, Hospital Central de Asturias, University of Oviedo. Reprint requests: Jorge Santos-Juanes, Servicio de Dermatología II, Hospital Central de Asturias, C/Julian Clavería s/n, 33006 Oviedo, Asturias, Spain. Copyright © 2001 by the American Academy of Dermatology, Inc. 0190-9622/2001/$35.00 + 0 16/54/117400 doi:10.1067/mjd.2001.117400
major etiologic agents.2,3 The recent emergence of increased virulence among GABHS isolates has renewed interest in complications caused by this pathogen. We report our experience with a patient who required pediatric intensive care unit (PICU) admission because of a serious GABHS infection 1 week after the onset of varicella. To our knowledge this has not been described in dermatologic publications.
CASE REPORT A 2-year-old boy was admitted to a local hospital with a 5-day history of varicella and a 1-day history of left periorbital soft tissue inflammation that quickly progressed to the rest of the face and upper trunk (Fig 1). There were multiple varicella lesions in normal evolution and two large edematous lesions on the face. He was treated by his pediatrician with oral acyclovir on the day before admission. On examination the patient was irritable and lethargic. He had poor perfusion with a capillary refill of 5 seconds. Vital signs were blood pressure, 110/70 mm Hg; pulse, 160; respirations, 30; and temperature,
Brief reports 771
J AM ACAD DERMATOL VOLUME 45, NUMBER 5
Fig 1. Varicella lesions on upper trunk and edema of face.
Fig 2. Ten days later necrotic lesion of upper left eyelid after surgical drainage.
38.9°C. The patient was given a single dose of cefotaxime and clindamycin and then transferred to our PICU. After stabilization with volume, the peripheral perfusion was good. Laboratory results included a white blood cell count of 10,500 cells/mm3 with 45% segmented neutrophils and 1% bands. Cefotaxime and clindamycin were administered. An axial tomographic scan showed a preseptal cellulitis of the face. Ten days later, the patient required periorbital surgical drainage of 25 mL of purulent material that was positive for GABHS (Fig 2). At this moment clindamycin was stopped and cefotaxime was maintained for an additional 5 days. Blood cultures were negative. He was transferred to the ward where the evolution was torpid, needing 2 more surgical procedures to drain the lesion. Amoxicillin with clavulanate was administered for 10 days and, finally, the patient recovered without problems.
Table I. Group A β-hemolytic streptococcal complications of chickenpox2,6-9
DISCUSSION Varicella is usually a benign and self-limited disease. In a recent epidemiologic study, Choo et al4 observed an overall complication rate within 30 days after the onset of primary varicella of 205 per 10,000 cases. The most common serious complications include soft tissue infections, pneumonia, dehydration, and central nervous system involvement. Bacterial infections are facilitated by disruption of the skin barrier and transient virus-induced alterations of immune functions. GABHS and S aureus are the major etiologic agents. There are sporadic cases reported of GABHS invasive disease in previously healthy children. A number of recent reports have noted an apparent increase in the number of patients with invasive GABHS infections. This increase resulted from the rise in varicella-associated cases. Doctor, Harper, and Fleischer5 reported that 50% of new cases of invasive GABHS
Skin Impetigo Skin abscess Cellulitis Deep seated Necrotizing fasciitis Myositis Osteomyelitis Arthritis Pneumonia
Pericarditis Endocarditis Meningitis Epiglottitis Systemic Sepsis with focal infection Sepsis without focal infection Toxic shock–like syndrome
disease were associated with varicella infection. The apparent increase in both incidence and virulence of GABHS infections is thought to be a result of an increase in the number of virulent serotypes.1 A large number of GABHS clinical manifestations as a varicella complication were reported (Table I).2,6-9 In the spectrum of bacterial infections complicating chickenpox in children, the skin was the most common site and more than 70% of cases were caused by hemolytic streptococci. Cellulitis is the most common infection, but periorbital cellulitis has rarely been associated with varicella in the literature.2 The possible increasing relationship between serious GABHS infection and varicella must be recognized and treated aggressively. In primary infection, fever usually heralds the eruption of the exanthem by 1 to 2 days and has abated by the fourth to seventh day. A sudden increase in the fever, temperature greater than 39°C more than 3 days after the onset of the exanthem, or return of fever after defervescence should alert the clinician to possible superinfection with GABHS.5 Antibiotics to cover GABHS
772 Brief reports
may be important in early care of the seriously ill child presenting with varicella. Healthy children recovering from varicella can experience life-threatening invasive infections caused by GABHS. REFERENCES 1. Cowan MR, Primm PA, Scott SM, Abramo TJ, Wiebe RA. Serious group A beta-hemolytic streptococcal infections complicating varicella. Ann Emerg Med 1994;23:818-22. 2. Aebi C, Ahmed A, Ramilo O. Bacterial complications of primary varicella in children. Clin Infect Dis 1996;23:698-705. 3. Fleisher G, Henry W, McSorley M, Arbeter A, Plotkin S. Life threatening complications of varicella. Am J Dis Child 1981;135:896-9. 4. Choo PW, Donahue JG, Manson JE, Platt R. The epidemiology of varicella and its complications. J Infect Dis 1995;172:706-12.
J AM ACAD DERMATOL NOVEMBER 2001
5. Doctor A, Harper MB, Fleischer GR. Group A beta-hemolytic streptococcal bacteremia: historical overview, changing incidence, and recent association with varicella. Pediatrics 1995; 96:428-33. 6. Slack CL, Allen GC, Morrison JE, Garren KC, Robak MG. Post-varicella epiglottitis and necrotizing fasciitis. Pediatrics 2000;105: 13-6. 7. Kouwabunpat D, Hoffman J, Adler R. Varicella complicated by group A streptococcal sepsis and osteonecrosis. Pediatrics 1999;104:967-9. 8. Mencia S, Riaza M, Valdivieso A, Casado J. Sepsis y empiema por estreptococo betahemolítico del grupo A en el curso de una varicela. An Esp Pediatr 1999;51:189-99. 9. Wheeler DS, Vazquez WD, Vaux KK, Poss WB. Streptococcal pyomiositis: case report and review. Pediatr Emerg Care 1998; 14:411-2.
J AM ACAD DERMATOL NOVEMBER 2001
Varicella complicated by group A streptococcal facial cellulitis J. Santos-Juanes,a A. Medina,b A. Concha,b C. Galache,a J. Sánchez del Río,a and C. Reyb Oviedo, Spain An increase has been recently noted in the incidence of life-threatening group A β-hemolytic streptococcal (GABHS) infections in children recovering from varicella. We report our experience with a patient who required pediatric intensive care unit admission because of a serious GABHS infection 1 week after the onset of varicella. Emergency physicians must look for this complication in patients with varicella remaining abnormally febrile and presenting unusual manifestations. (J Am Acad Dermatol 2001;45:770-2.)
V
aricella is usually a benign and self-limited disease manifested by mild systemic symptoms, characteristic rash, and low-grade fever.1 In Asturias, the incidence of varicella is 476.8 per 100,000 population. Serious problems related to varicella in the immunocompetent patient are relatively rare, although minor complications are common. Bacterial infections, which are facilitated by disruption of the skin barrier and possibly by transient virus-induced alterations of the immune functions, are prominent among the complications of varicella in normal children. Group A β-hemolytic streptococcus (GABHS) and Staphylococcus aureus are the
From the Service of Dermatology II,a and the Pediatric Intensive Care Unit,b Department of Pediatrics, Hospital Central de Asturias, University of Oviedo. Reprint requests: Jorge Santos-Juanes, Servicio de Dermatología II, Hospital Central de Asturias, C/Julian Clavería s/n, 33006 Oviedo, Asturias, Spain. Copyright © 2001 by the American Academy of Dermatology, Inc. 0190-9622/2001/$35.00 + 0 16/54/117400 doi:10.1067/mjd.2001.117400
major etiologic agents.2,3 The recent emergence of increased virulence among GABHS isolates has renewed interest in complications caused by this pathogen. We report our experience with a patient who required pediatric intensive care unit (PICU) admission because of a serious GABHS infection 1 week after the onset of varicella. To our knowledge this has not been described in dermatologic publications.
CASE REPORT A 2-year-old boy was admitted to a local hospital with a 5-day history of varicella and a 1-day history of left periorbital soft tissue inflammation that quickly progressed to the rest of the face and upper trunk (Fig 1). There were multiple varicella lesions in normal evolution and two large edematous lesions on the face. He was treated by his pediatrician with oral acyclovir on the day before admission. On examination the patient was irritable and lethargic. He had poor perfusion with a capillary refill of 5 seconds. Vital signs were blood pressure, 110/70 mm Hg; pulse, 160; respirations, 30; and temperature,
Brief reports 771
J AM ACAD DERMATOL VOLUME 45, NUMBER 5
Fig 1. Varicella lesions on upper trunk and edema of face.
Fig 2. Ten days later necrotic lesion of upper left eyelid after surgical drainage.
38.9°C. The patient was given a single dose of cefotaxime and clindamycin and then transferred to our PICU. After stabilization with volume, the peripheral perfusion was good. Laboratory results included a white blood cell count of 10,500 cells/mm3 with 45% segmented neutrophils and 1% bands. Cefotaxime and clindamycin were administered. An axial tomographic scan showed a preseptal cellulitis of the face. Ten days later, the patient required periorbital surgical drainage of 25 mL of purulent material that was positive for GABHS (Fig 2). At this moment clindamycin was stopped and cefotaxime was maintained for an additional 5 days. Blood cultures were negative. He was transferred to the ward where the evolution was torpid, needing 2 more surgical procedures to drain the lesion. Amoxicillin with clavulanate was administered for 10 days and, finally, the patient recovered without problems.
Table I. Group A β-hemolytic streptococcal complications of chickenpox2,6-9
DISCUSSION Varicella is usually a benign and self-limited disease. In a recent epidemiologic study, Choo et al4 observed an overall complication rate within 30 days after the onset of primary varicella of 205 per 10,000 cases. The most common serious complications include soft tissue infections, pneumonia, dehydration, and central nervous system involvement. Bacterial infections are facilitated by disruption of the skin barrier and transient virus-induced alterations of immune functions. GABHS and S aureus are the major etiologic agents. There are sporadic cases reported of GABHS invasive disease in previously healthy children. A number of recent reports have noted an apparent increase in the number of patients with invasive GABHS infections. This increase resulted from the rise in varicella-associated cases. Doctor, Harper, and Fleischer5 reported that 50% of new cases of invasive GABHS
Skin Impetigo Skin abscess Cellulitis Deep seated Necrotizing fasciitis Myositis Osteomyelitis Arthritis Pneumonia
Pericarditis Endocarditis Meningitis Epiglottitis Systemic Sepsis with focal infection Sepsis without focal infection Toxic shock–like syndrome
disease were associated with varicella infection. The apparent increase in both incidence and virulence of GABHS infections is thought to be a result of an increase in the number of virulent serotypes.1 A large number of GABHS clinical manifestations as a varicella complication were reported (Table I).2,6-9 In the spectrum of bacterial infections complicating chickenpox in children, the skin was the most common site and more than 70% of cases were caused by hemolytic streptococci. Cellulitis is the most common infection, but periorbital cellulitis has rarely been associated with varicella in the literature.2 The possible increasing relationship between serious GABHS infection and varicella must be recognized and treated aggressively. In primary infection, fever usually heralds the eruption of the exanthem by 1 to 2 days and has abated by the fourth to seventh day. A sudden increase in the fever, temperature greater than 39°C more than 3 days after the onset of the exanthem, or return of fever after defervescence should alert the clinician to possible superinfection with GABHS.5 Antibiotics to cover GABHS
772 Brief reports
may be important in early care of the seriously ill child presenting with varicella. Healthy children recovering from varicella can experience life-threatening invasive infections caused by GABHS. REFERENCES 1. Cowan MR, Primm PA, Scott SM, Abramo TJ, Wiebe RA. Serious group A beta-hemolytic streptococcal infections complicating varicella. Ann Emerg Med 1994;23:818-22. 2. Aebi C, Ahmed A, Ramilo O. Bacterial complications of primary varicella in children. Clin Infect Dis 1996;23:698-705. 3. Fleisher G, Henry W, McSorley M, Arbeter A, Plotkin S. Life threatening complications of varicella. Am J Dis Child 1981;135:896-9. 4. Choo PW, Donahue JG, Manson JE, Platt R. The epidemiology of varicella and its complications. J Infect Dis 1995;172:706-12.
J AM ACAD DERMATOL NOVEMBER 2001
5. Doctor A, Harper MB, Fleischer GR. Group A beta-hemolytic streptococcal bacteremia: historical overview, changing incidence, and recent association with varicella. Pediatrics 1995; 96:428-33. 6. Slack CL, Allen GC, Morrison JE, Garren KC, Robak MG. Post-varicella epiglottitis and necrotizing fasciitis. Pediatrics 2000;105: 13-6. 7. Kouwabunpat D, Hoffman J, Adler R. Varicella complicated by group A streptococcal sepsis and osteonecrosis. Pediatrics 1999;104:967-9. 8. Mencia S, Riaza M, Valdivieso A, Casado J. Sepsis y empiema por estreptococo betahemolítico del grupo A en el curso de una varicela. An Esp Pediatr 1999;51:189-99. 9. Wheeler DS, Vazquez WD, Vaux KK, Poss WB. Streptococcal pyomiositis: case report and review. Pediatr Emerg Care 1998; 14:411-2.