Scandinavian Journal of Infectious Diseases
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Fatal Varicella Pneumonia Jan Sander, Arne Serck-Hanssen & Jan C. Ulstrup To cite this article: Jan Sander, Arne Serck-Hanssen & Jan C. Ulstrup (1970) Fatal Varicella Pneumonia, Scandinavian Journal of Infectious Diseases, 2:3, 231-234 To link to this article: http://dx.doi.org/10.3109/inf.1970.2.issue-3.14
Published online: 02 Jan 2015.
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Date: 07 November 2015, At: 14:44
Scand J Infect Dis 2: 231-234, 1970
CASE REPORT
FATAL VARICELLA PNEUMONIA Jan Sander, Arne Serck-Hanssen and Jan C. Ulstrup
Downloaded by [Australian National University] at 14:44 07 November 2015
From the Department of Infectious Diseases, the Department of Pathology and the Bacteriological/Virological Laboratory, Ulleval Hospital, Oslo, Norway
ABSTRACT. A case of fatal varicella pneumonia in a 37-year-old woman is described. The clinical diagnosis was supported by the post-mortem examination which revealed extensive involvement of the hmgs, skin and liver. Varicella virus was isolated from vesicular fluid and fluid obtained at lung puncture after death. No predisposing factor was fonnd that could explain the fatal outcome of the infection.
Chickenpox is usually a benign disease, mainly affecting children and without serious complications. In 1873 Trousseau (13) stated that apart from incidental complications "no physician has ever seen a patient die of chickenpox". Since then, however, it has become evident that the disease may take a fulminant course and even terminate fatally, especially in adults. The majority of these patients die because of a varicella pneumonia (12). Varicella pneumonia is a rather common complication in adults contracting the disease. In a survey among adult men with varicella, Weber and Pellicchia (14) found that 16% had radiological signs of pneumonia. Among adults hospitalized for varicella, Mermelstein and Freireich (10) found that 34 % had pneumonia. These findings are also supported by others (2, 12). In 1967 Triebwasser et al. (12) found that of the 253 previously reported adults with varicella pneumonia 13.5 % terminated fatally. This high mortality rate reflects illnesses in patients predisposed to infection, especially those receiving corticosteroids or anti metabolites, or during pregnancy (7). From Scandinavia has previously been reported only one patient with varicella pneumonia, a pregnant woman who recovered after in-
termittent positive-pressure ventilation (11). Familial occurrence of fatal varicella pneumonia has been reported (8), but the authors failed to reveal any immunological or other inheritable defect that could explain the malignant course of the disease in their patients. The purpose of this communication is to report a further case of fatal varicella pneumonia, proven by autopsy and virological findings, in a patient where no obvious predisposing condition was discovered. CASE REPORT The patient was a 37-year-old female. She had never been seriously iII prior to her fatal disease. Two weeks prior to her illness 3 of her children had been febrile with a varicelliform eruption. Two days before she was admitted, she called her family doctor because of lumbar pain contracted during house cleaning. She had no fever, but the doctor noticed a pale rash localized to both cheeks. He was unable to make a definite diagnosis until the next day when the rash was generalized with a typical varicelliform appearance. In the afternoon on that day the patient felt febrile and became slightly dyspneic. Her symptoms increased in severity, and she was admitted at midnight the following day. On admission she was mentally confused and extremely cyanotic, with severe respiratory distress. Neither periferal pulse nor blood pressure could be registered. The extremities were cold and cyanotic. The heart rate was 110 and the body temperature 36.7°C. A varicelliform eruption was generally distributed with numerous petechial hemorrhages. There were coarse rales over both lungs. ECG showed sinus tachycardia without signs of peri- or myocarditis. Emergency treatment was started with oxygen and lanatoside C intravenously, but before further treatment or laboratory procedures could be initiated, the patient
Scand J Infect Dis 2
232
J. Sand er et al.
Downloaded by [Australian National University] at 14:44 07 November 2015
•
Fig. 1. Appear ance of rash on the right side of the abdomen (at postmortem).
died I hou r after ad mission. Six ho urs after death fluid was aspira ted from the lungs and ski n vesicles, and b lood was obtai ned by car diac pun cture for viro logical and bacteriological studies.
intr aep iderm al vesicles with some degree of reti cular and mar ked degree of ballooning degenerat ion of the ep iderm al cells of the stratum M alp ighii. M any degenerated epidermal cells cont ained eosinophilic intranu clear inclu sion bodies. Intracytopl asmatic inclusion bodies were not observed. The vesicles conta ined in addit ion to degene rat ed and necro tic epithelial cells scattered neutrophil granulocytes and some red cells in the vesicular exudate. The upper dermi s showed acute inflamma tory reaction and extravasation of red cells (F ig. 2). No thro mbosed vessels were fou nd. Th e lungs sho wed in sections from all lob es areas of oedema and haemorrh ages with mononu clear infiltr ation in alveo lar septa and many macrophages in the alveoli. Many alveo lar lining cells and other mon onu clear cells contained eosino philic intranuclea r inclusio n bod ies (Fig. 3 a and b) th at also occasionally could be seen in ciliated bronchial epithelium. The re were focal areas with necrosis of alveolar septa, and ma ny alveoli cont ained fibrin-rich exudate. In gram- stain ed sections scattered groups of gram-positive cocci in heaps and occasion al chains were found , ma inly in the smaller bro nc hi and bron chioles. T he liver showed in all sections focal areas of necro sis with inconsta nt distribut ion within the lobule . The necrot ic areas varied in size from occup ying approx imately ' /. of a liver lobule down to collection s of 15-20 liver cells. Th e cyto plasma of the necro tic liver cells was homogeneous and more eosino philic tha n in the normal liver cells, nuclear stai ning was mostly absent but occasional pykn otic nuclei were seen. Some necro tic areas showed a mixed cellular infl ammatory reac tion (Fig. 4), in others no reaction was fo und. Intranuclear inclusion bodies were found in some of the injured liver cells after prol onged search. V irologica l and bacteriological findings Varicella virus was isolated on hum an fibrobl ast cultures from vesicular fluid and fluid ob tained at lung puncture
Postm ort em exam inatio n Postmo rtem exam ina tion was carried out 7 hours after death. Extern ally was a heemor rhagic, partl y vesicular eruption most pronounced on the trunk (Fig. 1). Th e hsemorrh agic areas varied from 1 ] /2 to 6 mm in diameter, and the vesicles were seen mainly in the larger ones. No vesicles showed umbilication. Petechial heemorrhages were present on the serosal sur faces of the pleura, pericardium and the dome of the liver. The lungs were heavy, with a tot al weight of 1 660 g. Th ey were firm with mar ked oedema and mult iple small hemorrhagic areas of consolida tion throughout all lobes. The pericardi al sac con tain ed 10 ml of hremorrhagic fluid. Th e heart was gene ra lly flabb y, otherw ise norm al. The liver weighed 1 310 g, was sof ter th an normal, and th e cut sur face showed diffusely sca tte red sma ll pale areas, 1-2 mm in diamet er, without consta nt zona l distributio n. The kidneys weighed 250 g, the cortex was pale and swollen. Th e remaining organs were macroscopi cally judged to be normal. Histological examination Significant microscopical changes were found in sections from skin , lungs and liver. Th e skin from areas with vesicular eruptions revealed Scand J Infect Dis 2
Fig. 2. Section from skin showing intr aepidermal vesicle with reticular (R) and ballooning (B) degeneration of epithelial cells. In some of the latter intra nuclear inclusion bodies are just visible. Extravasated red cells in upper dermis. Hemato xylin-eosin (H.E.), x 90.
Fatal varicella pneumonia afte r death. The identity of the isolates was verified in th e complement fixation test with th e virus attacked tube culture cells as an antigen against kno wn seru m. Attempted virus isolations from cardi ac blood and lung tis-
...... .
'
,
••
Downloaded by [Australian National University] at 14:44 07 November 2015
233
,
.
e •.. . : •• • •
.
t
..
•
' .
....
. .. .
, ,: ~......:.
.
~
,
~
•
-. Jt ~
Fig . 4. Section from liver showing area of necrosis with moderate leucocyte reaction. H.E., x 200.
sue obt ained post mortem were negative. No antibodies against varicella antigen were demonstr ated in the patient's serum with the complement fixation test. Ample gro wth of Streptococcus virida ns and mod erate gro wth of beta-h aemolytic streptococci were obtai ned from th e fluid aspirated from the lungs. Imm unoelectroph oresis on serum revealed increased concentration of IgA, probably pol yclon al.
DISCUSSION
Fi g. 3 a. Section from lung showin g intraalveolar macrophages and / or alveolar lining cells with intra nuclea r inclusion bodies (ar row and windo w). H.E., x 215.
F ig. 3 b. Larger magnification of window in Fig. 3 a, showing ch aracteristic appe arance of nuclei with inclus ion bodies. H .E., x 550.
A tentative diagnosis of fulminant varicella infection with complicating pneumonia was made clinically. D ifferential diagnoses considered were fulminant atypical smallpox, that also may be com plicated by pneumonia, and men ingococc al or other bacterial septicemia. The clinical diagnos is was supported by the histological examination of the skin lesions which showed intraepidermal vesicles with acidophilic, exclusively intr anucl ear inclusion bodies. This excluded smallpox , as the inclusion bod ies in this condition are predominantly in the cytoplasma (9). Histologically it could , however, be herpes zoster or herpes simplex virus infection, although the appearance of the rash rather precluded this. A somewhat unu sual feature was the haemorrhagic appearance of the skin lesions. Thi s was due to extravasat ion of red cells in the upper dermi s. The phenomenon has previously been observed in a case with simultaneous thrombocytopenic purpura (4). As no platelet count was performed in our patient, we are unable to conclude that the pathogenesis was similar. The histological changes in the lungs were largel y identical with those descr ibed by Frank Scand J In ject Dis 2
Downloaded by [Australian National University] at 14:44 07 November 2015
234
J. Sander et al.
(5) and Cheatham et al. (3), although definite inclusions in fibroblasts and endothelial cells as described by the latter were not observed. The presence of gram-positive cocci was not accompanied by any polymorphonuclear reaction. The colonies probably represent postmortal growth with little or no clinical significance. The changes in the liver were similar to those reported by Cheatham et al. (3). A probable infective etiology is supported by their inconstant distribution within the liver lobule, and incrimination of varicella by the finding of intranuclear inclusions morphologically similar to those in the epidermis and the lungs. The virological findings prove the clinical and pathoanatomical diagnosis of varicella infection. In view of the absence of antibodies in the patient's serum the infection is likely to be primary, although a secondary response as a sign of reinfection may have been prevented by the early death of the patient. As the death occurred in a late phase of an influenza epidemic, attempts were also made to isolate other viruses, especially influenza virus, but without success. It is accepted that cell-mediated immunity is of decisive importance quoad vitam in varicella and morbilli infections (1, 6), as these infections run an almost normal course in agammaglobulinaemic patients. There is no evidence from the history of the patient of any immunological defect, and the autopsy did not reveal any morphological abnormalities in the spleen or lymph nodes. Neither was the patient receiving any medicinal treatment prior to her illness, nor was she pregnant. The fatal outcome of the infection in the present case is therefore likely to be "accidental", but an unusually large infective dose from the primary cases in the family may have been contributory.
REFERENCES 1. Burnet, F. M.: Measles as an index of immunological function. Lancet 2: 610, 1968. 2. Carstairs, L. S. & Emond, R. T. D.: Chickenpox virus pneumonia. Proc Roy Soc Med 56: 267, 1963. 3. Cheatham, W. J., Weller, T. H., Dolan, T. F. & Dower, J. C.: Varicella: report of two fatal cases with necropsy, virus isolation and serological studies. Amer J Path 32: 1015, 1956. 4. Cohen, J. J. & Bansmer, C.: Chickenpox with simultaneous idiopathic thrombocytopenic purpura. Report of a case. New Eng J Med 237: 222, 1947. Scand J Infect Dis 2
5. Frank, L.: Varicella pneumonitis. Report of a case. Arch Path (Chicago) 50: 450, 1950. 6. Good, R. A, Finstad, J. & Gatti, R. A: Bulwarks of the bodily defense. In: Infectious Agents and Host Resistance, p. 76 (ed. S. Mudd). Saunders, Philadelphia 1970. 7. Harris, R. E. & Rhoades, E. R.: Varicella pneumonia complicating pregnancy. Report of a case and review of the literature. Obstet Gynec 25: 734, 1965. 8. Hook, E. 8., Orandi, M., Bensel, R. W., Schamber, W. F. & St. Geme, J. W.: Familial fatal varicella. JAMA 206: 305, 1965. 9. Lever, W. F.: Histopathology of the Skin, p. 369. 4th ed. Pitman Medical Publishing Co. Ltd., London, and J. B. Lippincott Co., Philadelphia 1967. 10. Mermelstein, R. H. & Freireich, A W.: Varicella pneumonia. Ann Intern Med 55: 456, 1961. 11. Tidstrem, 8.: Varicella pneumonia. Treatment with tracheostomy and mechanical endotracheal positive pressure ventilation. Scand J Resp Dis 48: 40, 1967. 12. Triebwasser, J. H., Harris, R. E., Bryant, R. E. & Rhoades, E. R.: Varicella pneumonia in adults. Medicine (Bait) 46: 409, 1967. 13. Trousseau, cited by Waring, J. J., Neuberger, K. & Geever, E. P.: Severe forms of chickenpox in adults with autopsy observations in a case with associated pneumonia and encephalitis. Arch Intern Med (Chicago) 69: 384, 1942. 14. Weber, D. M. & Pellicchia, J. A: Varicella pneumonia. Study of prevalence in adult men. JAM A 192: 288, 1965. J. Sander, M.D.,
Department of Infectious Diseases, Ullevtil Hospital, Oslo I, Norway
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Fatal Varicella Pneumonia Jan Sander, Arne Serck-Hanssen & Jan C. Ulstrup To cite this article: Jan Sander, Arne Serck-Hanssen & Jan C. Ulstrup (1970) Fatal Varicella Pneumonia, Scandinavian Journal of Infectious Diseases, 2:3, 231-234 To link to this article: http://dx.doi.org/10.3109/inf.1970.2.issue-3.14
Published online: 02 Jan 2015.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=infd19 Download by: [Australian National University]
Date: 07 November 2015, At: 14:44
Scand J Infect Dis 2: 231-234, 1970
CASE REPORT
FATAL VARICELLA PNEUMONIA Jan Sander, Arne Serck-Hanssen and Jan C. Ulstrup
Downloaded by [Australian National University] at 14:44 07 November 2015
From the Department of Infectious Diseases, the Department of Pathology and the Bacteriological/Virological Laboratory, Ulleval Hospital, Oslo, Norway
ABSTRACT. A case of fatal varicella pneumonia in a 37-year-old woman is described. The clinical diagnosis was supported by the post-mortem examination which revealed extensive involvement of the hmgs, skin and liver. Varicella virus was isolated from vesicular fluid and fluid obtained at lung puncture after death. No predisposing factor was fonnd that could explain the fatal outcome of the infection.
Chickenpox is usually a benign disease, mainly affecting children and without serious complications. In 1873 Trousseau (13) stated that apart from incidental complications "no physician has ever seen a patient die of chickenpox". Since then, however, it has become evident that the disease may take a fulminant course and even terminate fatally, especially in adults. The majority of these patients die because of a varicella pneumonia (12). Varicella pneumonia is a rather common complication in adults contracting the disease. In a survey among adult men with varicella, Weber and Pellicchia (14) found that 16% had radiological signs of pneumonia. Among adults hospitalized for varicella, Mermelstein and Freireich (10) found that 34 % had pneumonia. These findings are also supported by others (2, 12). In 1967 Triebwasser et al. (12) found that of the 253 previously reported adults with varicella pneumonia 13.5 % terminated fatally. This high mortality rate reflects illnesses in patients predisposed to infection, especially those receiving corticosteroids or anti metabolites, or during pregnancy (7). From Scandinavia has previously been reported only one patient with varicella pneumonia, a pregnant woman who recovered after in-
termittent positive-pressure ventilation (11). Familial occurrence of fatal varicella pneumonia has been reported (8), but the authors failed to reveal any immunological or other inheritable defect that could explain the malignant course of the disease in their patients. The purpose of this communication is to report a further case of fatal varicella pneumonia, proven by autopsy and virological findings, in a patient where no obvious predisposing condition was discovered. CASE REPORT The patient was a 37-year-old female. She had never been seriously iII prior to her fatal disease. Two weeks prior to her illness 3 of her children had been febrile with a varicelliform eruption. Two days before she was admitted, she called her family doctor because of lumbar pain contracted during house cleaning. She had no fever, but the doctor noticed a pale rash localized to both cheeks. He was unable to make a definite diagnosis until the next day when the rash was generalized with a typical varicelliform appearance. In the afternoon on that day the patient felt febrile and became slightly dyspneic. Her symptoms increased in severity, and she was admitted at midnight the following day. On admission she was mentally confused and extremely cyanotic, with severe respiratory distress. Neither periferal pulse nor blood pressure could be registered. The extremities were cold and cyanotic. The heart rate was 110 and the body temperature 36.7°C. A varicelliform eruption was generally distributed with numerous petechial hemorrhages. There were coarse rales over both lungs. ECG showed sinus tachycardia without signs of peri- or myocarditis. Emergency treatment was started with oxygen and lanatoside C intravenously, but before further treatment or laboratory procedures could be initiated, the patient
Scand J Infect Dis 2
232
J. Sand er et al.
Downloaded by [Australian National University] at 14:44 07 November 2015
•
Fig. 1. Appear ance of rash on the right side of the abdomen (at postmortem).
died I hou r after ad mission. Six ho urs after death fluid was aspira ted from the lungs and ski n vesicles, and b lood was obtai ned by car diac pun cture for viro logical and bacteriological studies.
intr aep iderm al vesicles with some degree of reti cular and mar ked degree of ballooning degenerat ion of the ep iderm al cells of the stratum M alp ighii. M any degenerated epidermal cells cont ained eosinophilic intranu clear inclu sion bodies. Intracytopl asmatic inclusion bodies were not observed. The vesicles conta ined in addit ion to degene rat ed and necro tic epithelial cells scattered neutrophil granulocytes and some red cells in the vesicular exudate. The upper dermi s showed acute inflamma tory reaction and extravasation of red cells (F ig. 2). No thro mbosed vessels were fou nd. Th e lungs sho wed in sections from all lob es areas of oedema and haemorrh ages with mononu clear infiltr ation in alveo lar septa and many macrophages in the alveoli. Many alveo lar lining cells and other mon onu clear cells contained eosino philic intranuclea r inclusio n bod ies (Fig. 3 a and b) th at also occasionally could be seen in ciliated bronchial epithelium. The re were focal areas with necrosis of alveolar septa, and ma ny alveoli cont ained fibrin-rich exudate. In gram- stain ed sections scattered groups of gram-positive cocci in heaps and occasion al chains were found , ma inly in the smaller bro nc hi and bron chioles. T he liver showed in all sections focal areas of necro sis with inconsta nt distribut ion within the lobule . The necrot ic areas varied in size from occup ying approx imately ' /. of a liver lobule down to collection s of 15-20 liver cells. Th e cyto plasma of the necro tic liver cells was homogeneous and more eosino philic tha n in the normal liver cells, nuclear stai ning was mostly absent but occasional pykn otic nuclei were seen. Some necro tic areas showed a mixed cellular infl ammatory reac tion (Fig. 4), in others no reaction was fo und. Intranuclear inclusion bodies were found in some of the injured liver cells after prol onged search. V irologica l and bacteriological findings Varicella virus was isolated on hum an fibrobl ast cultures from vesicular fluid and fluid ob tained at lung puncture
Postm ort em exam inatio n Postmo rtem exam ina tion was carried out 7 hours after death. Extern ally was a heemor rhagic, partl y vesicular eruption most pronounced on the trunk (Fig. 1). Th e hsemorrh agic areas varied from 1 ] /2 to 6 mm in diameter, and the vesicles were seen mainly in the larger ones. No vesicles showed umbilication. Petechial heemorrhages were present on the serosal sur faces of the pleura, pericardium and the dome of the liver. The lungs were heavy, with a tot al weight of 1 660 g. Th ey were firm with mar ked oedema and mult iple small hemorrhagic areas of consolida tion throughout all lobes. The pericardi al sac con tain ed 10 ml of hremorrhagic fluid. Th e heart was gene ra lly flabb y, otherw ise norm al. The liver weighed 1 310 g, was sof ter th an normal, and th e cut sur face showed diffusely sca tte red sma ll pale areas, 1-2 mm in diamet er, without consta nt zona l distributio n. The kidneys weighed 250 g, the cortex was pale and swollen. Th e remaining organs were macroscopi cally judged to be normal. Histological examination Significant microscopical changes were found in sections from skin , lungs and liver. Th e skin from areas with vesicular eruptions revealed Scand J Infect Dis 2
Fig. 2. Section from skin showing intr aepidermal vesicle with reticular (R) and ballooning (B) degeneration of epithelial cells. In some of the latter intra nuclear inclusion bodies are just visible. Extravasated red cells in upper dermis. Hemato xylin-eosin (H.E.), x 90.
Fatal varicella pneumonia afte r death. The identity of the isolates was verified in th e complement fixation test with th e virus attacked tube culture cells as an antigen against kno wn seru m. Attempted virus isolations from cardi ac blood and lung tis-
...... .
'
,
••
Downloaded by [Australian National University] at 14:44 07 November 2015
233
,
.
e •.. . : •• • •
.
t
..
•
' .
....
. .. .
, ,: ~......:.
.
~
,
~
•
-. Jt ~
Fig . 4. Section from liver showing area of necrosis with moderate leucocyte reaction. H.E., x 200.
sue obt ained post mortem were negative. No antibodies against varicella antigen were demonstr ated in the patient's serum with the complement fixation test. Ample gro wth of Streptococcus virida ns and mod erate gro wth of beta-h aemolytic streptococci were obtai ned from th e fluid aspirated from the lungs. Imm unoelectroph oresis on serum revealed increased concentration of IgA, probably pol yclon al.
DISCUSSION
Fi g. 3 a. Section from lung showin g intraalveolar macrophages and / or alveolar lining cells with intra nuclea r inclusion bodies (ar row and windo w). H.E., x 215.
F ig. 3 b. Larger magnification of window in Fig. 3 a, showing ch aracteristic appe arance of nuclei with inclus ion bodies. H .E., x 550.
A tentative diagnosis of fulminant varicella infection with complicating pneumonia was made clinically. D ifferential diagnoses considered were fulminant atypical smallpox, that also may be com plicated by pneumonia, and men ingococc al or other bacterial septicemia. The clinical diagnos is was supported by the histological examination of the skin lesions which showed intraepidermal vesicles with acidophilic, exclusively intr anucl ear inclusion bodies. This excluded smallpox , as the inclusion bod ies in this condition are predominantly in the cytoplasma (9). Histologically it could , however, be herpes zoster or herpes simplex virus infection, although the appearance of the rash rather precluded this. A somewhat unu sual feature was the haemorrhagic appearance of the skin lesions. Thi s was due to extravasat ion of red cells in the upper dermi s. The phenomenon has previously been observed in a case with simultaneous thrombocytopenic purpura (4). As no platelet count was performed in our patient, we are unable to conclude that the pathogenesis was similar. The histological changes in the lungs were largel y identical with those descr ibed by Frank Scand J In ject Dis 2
Downloaded by [Australian National University] at 14:44 07 November 2015
234
J. Sander et al.
(5) and Cheatham et al. (3), although definite inclusions in fibroblasts and endothelial cells as described by the latter were not observed. The presence of gram-positive cocci was not accompanied by any polymorphonuclear reaction. The colonies probably represent postmortal growth with little or no clinical significance. The changes in the liver were similar to those reported by Cheatham et al. (3). A probable infective etiology is supported by their inconstant distribution within the liver lobule, and incrimination of varicella by the finding of intranuclear inclusions morphologically similar to those in the epidermis and the lungs. The virological findings prove the clinical and pathoanatomical diagnosis of varicella infection. In view of the absence of antibodies in the patient's serum the infection is likely to be primary, although a secondary response as a sign of reinfection may have been prevented by the early death of the patient. As the death occurred in a late phase of an influenza epidemic, attempts were also made to isolate other viruses, especially influenza virus, but without success. It is accepted that cell-mediated immunity is of decisive importance quoad vitam in varicella and morbilli infections (1, 6), as these infections run an almost normal course in agammaglobulinaemic patients. There is no evidence from the history of the patient of any immunological defect, and the autopsy did not reveal any morphological abnormalities in the spleen or lymph nodes. Neither was the patient receiving any medicinal treatment prior to her illness, nor was she pregnant. The fatal outcome of the infection in the present case is therefore likely to be "accidental", but an unusually large infective dose from the primary cases in the family may have been contributory.
REFERENCES 1. Burnet, F. M.: Measles as an index of immunological function. Lancet 2: 610, 1968. 2. Carstairs, L. S. & Emond, R. T. D.: Chickenpox virus pneumonia. Proc Roy Soc Med 56: 267, 1963. 3. Cheatham, W. J., Weller, T. H., Dolan, T. F. & Dower, J. C.: Varicella: report of two fatal cases with necropsy, virus isolation and serological studies. Amer J Path 32: 1015, 1956. 4. Cohen, J. J. & Bansmer, C.: Chickenpox with simultaneous idiopathic thrombocytopenic purpura. Report of a case. New Eng J Med 237: 222, 1947. Scand J Infect Dis 2
5. Frank, L.: Varicella pneumonitis. Report of a case. Arch Path (Chicago) 50: 450, 1950. 6. Good, R. A, Finstad, J. & Gatti, R. A: Bulwarks of the bodily defense. In: Infectious Agents and Host Resistance, p. 76 (ed. S. Mudd). Saunders, Philadelphia 1970. 7. Harris, R. E. & Rhoades, E. R.: Varicella pneumonia complicating pregnancy. Report of a case and review of the literature. Obstet Gynec 25: 734, 1965. 8. Hook, E. 8., Orandi, M., Bensel, R. W., Schamber, W. F. & St. Geme, J. W.: Familial fatal varicella. JAMA 206: 305, 1965. 9. Lever, W. F.: Histopathology of the Skin, p. 369. 4th ed. Pitman Medical Publishing Co. Ltd., London, and J. B. Lippincott Co., Philadelphia 1967. 10. Mermelstein, R. H. & Freireich, A W.: Varicella pneumonia. Ann Intern Med 55: 456, 1961. 11. Tidstrem, 8.: Varicella pneumonia. Treatment with tracheostomy and mechanical endotracheal positive pressure ventilation. Scand J Resp Dis 48: 40, 1967. 12. Triebwasser, J. H., Harris, R. E., Bryant, R. E. & Rhoades, E. R.: Varicella pneumonia in adults. Medicine (Bait) 46: 409, 1967. 13. Trousseau, cited by Waring, J. J., Neuberger, K. & Geever, E. P.: Severe forms of chickenpox in adults with autopsy observations in a case with associated pneumonia and encephalitis. Arch Intern Med (Chicago) 69: 384, 1942. 14. Weber, D. M. & Pellicchia, J. A: Varicella pneumonia. Study of prevalence in adult men. JAM A 192: 288, 1965. J. Sander, M.D.,
Department of Infectious Diseases, Ullevtil Hospital, Oslo I, Norway
