Scot Med J 1992; 37: 185
0036-9330/92/06192/185 $2.00 in USA © 1992 Scottish Medical Journal
ABSCESS FORMATION AS A COMPLICATION OF CHICKENPOX C.M. Guthrie Departmentof Accidentand Emergency,Royal Infrrmary, 1 LauristonPlace,Edinburgh. Abstract: Chickenpoxis a commoninfectiousdiseaseofchildhood. Skin lesions may occasionallybecomesecondarily infectedwithbacteria.Large abscessformationis reportedcomplicating a mildcaseofchickenpoxin apreviouslyhealthy patient. Key words: Varicella, abscess, beta-haemolytic streptococci.
Introduction aricella (chickenpox) is a highly infectious but benign disorder due toprimaryinfectionwiththe varicellazostervirus. Occasional complications of pneumonia and, less commonly, encephalitis have been noted to complicate varicella. Secondary infection of varicella vesicles has been reported previously but without formation of any substantialcollectionof pus.
V
Case report A previously healthy twenty-four year old male presented to the accident and emergency department with a five day history of increasing lower back pain and swelling. He had contracted chickenpox two weeks previously. This consisted of typical skin lesions affecting trunk, limbs, and scalp but without mucous membrane involvement and with no significant constitutional upset. The diagnosis was made by his general practitioner and, at the time of presentation to hospital, all the skin vescles had crusted with the formation of scabs. The patient felt well apart from the recent development of a painful swelling of his back. He had no past history of note and was not taking any medications. On examination, he had a pyrexia of38.2 degrees celsius and was unable to lie on his back because of a 40 by 25 centimetre fluctuant, tender swelling. This extended from mid-thoracic region to natal cleft and laterally to both flanks. A large healing scab with minimal surrounding erythema was situated centrally over this swelling but there was no other evidence of involvement of overlying skin. Mild inguinal and axillary lymphadenopathy was noted but other examination was normal. Investigation on presentation revealed a white cell count of 24,300 cells/rnillilitre (92% neutrophils, 6% lymphocytes, 2% monocytes). Chest x-ray was normal. Test for human immunodeficiency virus antibody was negative. Aspiration ofthe swelling revealed blood-stained pus and under general anaesthetic, two and a half litres of pus and blood were drained from a large abscess through a midline incision. There was no evidence of extension beyond subcutaneous tissues seen at operation and the large resultant cavity was packed following a thorough saline washout. Bacteriological culture of the pus grew group-A beta-haemolytic streptococci. No acid and alchohol fast bacilli or other organisms were grown on culture. The only portal of entry for the organism was the overlying varicella vesicle which was concluded to be the cause of the abscess.
Discussion Chickenpox is a generally benign disease and pneumonia and encephalitis are only occasional complications. However, the skin lesions may become infected with pyogenic organismsand Correspondence and reprint requests to: Dr CM Guthrie, University Department of Surgery, Royal Infirmary, 1 Lauriston Place, Edinburgh EH3 9YW.
rarely, extensive cellulitis or gangrene may occur. Reports of "varicellagangrenosa" emphasisethepotentially serioussequelae that can result when the primary lesions of varicella afford a special portal of entry for Streptococcus pyogenes.1,2 Varicellagangrenosawasa termfirstusedby Hutchison in 1882 to describe necrotic patches which occasionally appear on the skin during chickenpox.f These gangrenous areas may spread rapidly, with little developmentof pus, and profound toxaemia may ensue, leading even to death.4 Necrotising fasciitis and pyomyositis have also been linked to varicella with potentially fatal outcomes but not typically with developmentof pus.5 ,6 Varicellaresults in full thicknessskin lesionsthat may become secondarily infected. An intra-epidermal split occursresulting in reticulardegeneration andacantholysis. Thisrent intheepidermis becomesfilled withprotein-richvesiclefluid whichmayprovide a suitablemediumforproliferationof bacteria? In 1935,Bullowa and Wishik reportedinfectionas a complication of varicellaskin lesions but these were relatively minor problemsin comparison to other complications reported.8 In this case, a previously healthy male has developed superinfection of a varicella vesicle with production of a large abscess cavity. The considerable accumulation of pus was not associatedwithoverlyingskin erythemaand showedno evidence of extensioninto muscle. Infectionassociatedwith varicellavesicles has been previously reported but not with the developmentof a large abscesscavity. In this case, massive abscess formation has added considerable morbidityto a mild case of varicella. REFERENCES ·1 AndimanWA, Soifer S. Severe streptococcal infectioncomplicating chickenpox.Clin Paediatr 1980;19(7):495-496. 2 Smith EWP, Garson A, Boyleston JA, Katz SL, Wilfert CM. Varicella gangrenosa dueto groupAbeta-haemolytic streptococcus. Paediatrics 1976; 57: 306. 3 Hutchison J. On gangrenous eruptions in connection with vaccination and chickenpox. Moo Chir Trans 1882; 65:1 4 StorrieHC.Haemorrhagic andgangrenous varicella, withnotesof twocases. BrJ ChildDis 1914; 11:62. 5 FalconePA,PricoloVE,Edstrom LE.Necrotizing fasciitis asa complication of chickenpox. Clin Paediatr. 1988;27(7):339-343. 6 RaphaelSA, Longenecker SC,WolfsonBJ, FiscerMC. Post-varicella streptococcalpyomyositis. PaediatrJnf Dis J 1989;8(3): 187-189. 7 FulginitiV. Varicella(chickenpox). In: ClinicalDermatology. EdDernis OJ, CrounseRG, DobsonRL, McGuireJ. Hagerston Harper& Pow 1972;vol 3; section14-16:pps2-3. 8 BullowaJGM, WishikSM. Complications of varicella. Am J Dis Ch 1935; 49:923-926.
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0036-9330/92/06192/185 $2.00 in USA © 1992 Scottish Medical Journal
ABSCESS FORMATION AS A COMPLICATION OF CHICKENPOX C.M. Guthrie Departmentof Accidentand Emergency,Royal Infrrmary, 1 LauristonPlace,Edinburgh. Abstract: Chickenpoxis a commoninfectiousdiseaseofchildhood. Skin lesions may occasionallybecomesecondarily infectedwithbacteria.Large abscessformationis reportedcomplicating a mildcaseofchickenpoxin apreviouslyhealthy patient. Key words: Varicella, abscess, beta-haemolytic streptococci.
Introduction aricella (chickenpox) is a highly infectious but benign disorder due toprimaryinfectionwiththe varicellazostervirus. Occasional complications of pneumonia and, less commonly, encephalitis have been noted to complicate varicella. Secondary infection of varicella vesicles has been reported previously but without formation of any substantialcollectionof pus.
V
Case report A previously healthy twenty-four year old male presented to the accident and emergency department with a five day history of increasing lower back pain and swelling. He had contracted chickenpox two weeks previously. This consisted of typical skin lesions affecting trunk, limbs, and scalp but without mucous membrane involvement and with no significant constitutional upset. The diagnosis was made by his general practitioner and, at the time of presentation to hospital, all the skin vescles had crusted with the formation of scabs. The patient felt well apart from the recent development of a painful swelling of his back. He had no past history of note and was not taking any medications. On examination, he had a pyrexia of38.2 degrees celsius and was unable to lie on his back because of a 40 by 25 centimetre fluctuant, tender swelling. This extended from mid-thoracic region to natal cleft and laterally to both flanks. A large healing scab with minimal surrounding erythema was situated centrally over this swelling but there was no other evidence of involvement of overlying skin. Mild inguinal and axillary lymphadenopathy was noted but other examination was normal. Investigation on presentation revealed a white cell count of 24,300 cells/rnillilitre (92% neutrophils, 6% lymphocytes, 2% monocytes). Chest x-ray was normal. Test for human immunodeficiency virus antibody was negative. Aspiration ofthe swelling revealed blood-stained pus and under general anaesthetic, two and a half litres of pus and blood were drained from a large abscess through a midline incision. There was no evidence of extension beyond subcutaneous tissues seen at operation and the large resultant cavity was packed following a thorough saline washout. Bacteriological culture of the pus grew group-A beta-haemolytic streptococci. No acid and alchohol fast bacilli or other organisms were grown on culture. The only portal of entry for the organism was the overlying varicella vesicle which was concluded to be the cause of the abscess.
Discussion Chickenpox is a generally benign disease and pneumonia and encephalitis are only occasional complications. However, the skin lesions may become infected with pyogenic organismsand Correspondence and reprint requests to: Dr CM Guthrie, University Department of Surgery, Royal Infirmary, 1 Lauriston Place, Edinburgh EH3 9YW.
rarely, extensive cellulitis or gangrene may occur. Reports of "varicellagangrenosa" emphasisethepotentially serioussequelae that can result when the primary lesions of varicella afford a special portal of entry for Streptococcus pyogenes.1,2 Varicellagangrenosawasa termfirstusedby Hutchison in 1882 to describe necrotic patches which occasionally appear on the skin during chickenpox.f These gangrenous areas may spread rapidly, with little developmentof pus, and profound toxaemia may ensue, leading even to death.4 Necrotising fasciitis and pyomyositis have also been linked to varicella with potentially fatal outcomes but not typically with developmentof pus.5 ,6 Varicellaresults in full thicknessskin lesionsthat may become secondarily infected. An intra-epidermal split occursresulting in reticulardegeneration andacantholysis. Thisrent intheepidermis becomesfilled withprotein-richvesiclefluid whichmayprovide a suitablemediumforproliferationof bacteria? In 1935,Bullowa and Wishik reportedinfectionas a complication of varicellaskin lesions but these were relatively minor problemsin comparison to other complications reported.8 In this case, a previously healthy male has developed superinfection of a varicella vesicle with production of a large abscess cavity. The considerable accumulation of pus was not associatedwithoverlyingskin erythemaand showedno evidence of extensioninto muscle. Infectionassociatedwith varicellavesicles has been previously reported but not with the developmentof a large abscesscavity. In this case, massive abscess formation has added considerable morbidityto a mild case of varicella. REFERENCES ·1 AndimanWA, Soifer S. Severe streptococcal infectioncomplicating chickenpox.Clin Paediatr 1980;19(7):495-496. 2 Smith EWP, Garson A, Boyleston JA, Katz SL, Wilfert CM. Varicella gangrenosa dueto groupAbeta-haemolytic streptococcus. Paediatrics 1976; 57: 306. 3 Hutchison J. On gangrenous eruptions in connection with vaccination and chickenpox. Moo Chir Trans 1882; 65:1 4 StorrieHC.Haemorrhagic andgangrenous varicella, withnotesof twocases. BrJ ChildDis 1914; 11:62. 5 FalconePA,PricoloVE,Edstrom LE.Necrotizing fasciitis asa complication of chickenpox. Clin Paediatr. 1988;27(7):339-343. 6 RaphaelSA, Longenecker SC,WolfsonBJ, FiscerMC. Post-varicella streptococcalpyomyositis. PaediatrJnf Dis J 1989;8(3): 187-189. 7 FulginitiV. Varicella(chickenpox). In: ClinicalDermatology. EdDernis OJ, CrounseRG, DobsonRL, McGuireJ. Hagerston Harper& Pow 1972;vol 3; section14-16:pps2-3. 8 BullowaJGM, WishikSM. Complications of varicella. Am J Dis Ch 1935; 49:923-926.
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