Hemorrhagic Varicella in Chronic Liver Disease
A 12-year-old boy, follow-up case of chronic liver disease, was admitted in our hospital with 1-week history of fever, malaise and 5 days history of generalized discrete vesiculopustular rash over the entire body and oral ulcers. His palms and soles were also involved. Since the last 3 days, the rash became hemorrhagic with frank bleeding from several areas especially from the lesions on the face and also had malena. Since then, the patient became anorexic and weak. There was family history of similar illness in two younger siblings but of mild in nature and rashes were subsided in them without any treatment. He had history of jaundice off and on and abdominal distension since last 1 year. He was hospitalized two times for the complaint of jaundice and abdominal distension in the past 1 year. The patient belonged to a poor social background. On examination, the patient was looking toxic and he was conscious and oriented. He was febrile (temperature: 38.5°C) and had severe pallor. There were several hemorrhagic ulcers in his mouth and over the lips, multiple large hemorrhagic rashes over the face [], with frank bleeding from a few lesions and multiple discrete hemorrhagic pustules over the entire body [Figures and ]. On per abdominal examination spleen was palpable 8 cm below costal margin and liver was palpable 3cm below costal margin. On investigations, hemoglobin level was 4.7 g/dl, total leukocyte count was 4.3 × 109/l and platelets were 29 × 109/l and ESR was 65 mm fall. Serum bilirubin was 3.0 mg/dl, serum albumin was 2.3 g/dl with SGOT 154 and SGPT 88. Prothrombin and thromboplastin time were also prolonged. Level of serum urea was 31 mg/dl and creatinine was 0.98 mg/dl. The patient was HBsAg negative and antibodies to hepatitis-C were absent. ELISA test for HIV was negative. Abdominal ultrasonography revealed hepatosplenomegaly with coarse echotexture of liver with portal vein dilatation. Tzanck smear revealed multinucleated giant cells. Anti-varicella IgM antibodies were positive. We did not perform liver biopsy because patient's general condition was low and he had thrombocytopenia too. On the basis of clinical condition and laboratory parameters the diagnosis of chronic liver disease with hemorrhagic chickenpox was made. During the hospital stay the patient has also developed pneumonia on day 2 of admission. We have given aggressive supportive treatment as well as intravenous acyclovir 10 mg/kg 8 hourly, intravenous antibiotics, including cefotaxime 75 mg/kg 12 hourly and vancomycin 15 mg/kg 8 hourly to him for 10 days and were transfused packed cell volume along with platelet concentrate and fresh frozen plasma. Fortunately the patient got improved on day 7 and we discharged him and referred to higher center on day 10 for further management of his chronic liver disease. Written consent was obtained from the patient's father for the publication of case report along with photographs.