1. Hemorrhagic varicella
Davorka Dušek, Sofiya Andreykanich, Neven Papić, Ivan Kurelac, Adriana Vince

2. History
A 72-year old woman with chronic lymphocytic leukemia presented with a pruritic rash and fever up to 40.2 °C that started two days prior to admission.
She also reported a 1-week history of fatigue, malaise, myalgia and loss of appetite.
Chronic lymphocytic leukemia was diagnosed in 2016, RAI IV, she didn’t receive any specific therapy.
Patient’s son has recently been treated because of ophthalmic herpes zoster.

3. Pictures of skin changes
The physical examination revealed pruritic hemorrhagic papules and vesicles on her chest, abdomen, thighs, upper arms and head.
Distribution of skin changes was typical for varicella, there were no signs of disseminated herpes zoster

4. Laboratory workup/treatment
WBC 22.6 x 109/ L with lymphocytosis (81%), Hb 98 g/L, Plt 53 x 109/ L
Diagnosis was confirmed by polymerase-chain-reaction that identified varicella-zoster virus DNA in vesicle smear.
Cytological examination of vesicle smear did not detect multinuclear giant epithelial cells.
Patient was successfully treated with acyclovir and she also received cefazolin because of partial impetiginization of some skin changes.
There was no visceral or neurological involvement

5. Varicella in the immunosuppressed host
Patients with underlying malignancy, steroid use or immunosuppressive therapy, HIV infection, solid organ transplantation of hematopoietic cell transplantation are susceptible for disseminated varicella due to impaired cellular immunity
Clinical manifestations can include:
* ongoing development of crops of vesicles over weeks
* large and hemorrhagic skin lesions
* pneumonia
* widespread disease with disseminated intravascular coagulation