Acta Oncologica

ISSN: 0284-186X (Print) 1651-226X (Online) Journal homepage: http://www.tandfonline.com/loi/ionc20

Simultaneous Disseminated Herpes Zoster and Bacterial Infection in Cancer Patients Abdel G. Maiche, Michael J. Kajanti & Seppo Pyrhonen To cite this article: Abdel G. Maiche, Michael J. Kajanti & Seppo Pyrhonen (1992) Simultaneous Disseminated Herpes Zoster and Bacterial Infection in Cancer Patients, Acta Oncologica, 31:6, 681-683, DOI: 10.3109/02841869209083855 To link to this article: http://dx.doi.org/10.3109/02841869209083855

Published online: 08 Jul 2009.

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and under the influence of /I-adrenergic receptors (24). Irrespective of blood flow, skeletal muscle tissue seems to be a poor milieu for tumors and this may be related to the lactic acid metabolism (4, 5, 21). However, skeletal muscles are easily subjected to trauma, and it has been shown that trauma of local areas may promote the growth of metastasis either by the release of growth promoting factors or as a trapping site for circulating tumor cells (25, 26).

ACKNOWLEDGEMENTS The authors would like to express their gratitude to Dr P. F. Giriodi and Dr A. Comino for technical assistance.

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DOMENICO FERRIGNO Medical Department GIANFRANCO BUCCHERI A. Carle Hospital of Chest Diseases Cuneo Italy April 1992 Correspondence to: Dr D. Ferrigno Medical Department, A. Carle Hospital of Chest Diseases, 1-12100 Cuneo, Italy.

REFERENCES I . Beurger LC, Monteleone PN. Leukemic lymphomatous infiltration of skeletal muscle. Cancer 1966; 19: 1416-21. 2. Rotterdam H, Slavutin L. Secondary tumors of soft tissues: An autopsy study. In: Fenoglio CM, Wolff M, eds. Progress in surgical pathology, vol. 3, New York: Masson, 1980: 14768. 3. Willis RA. The spread of tumors in the human body. London: Butterwork, 1973; 282. 4. Delaney WE. Non-myogenic tumors involving skeletal muscle: A survey with special reference to alveolar soft part sarcoma. Ann Clin Sci 1975; 5: 236-41. 5. Rubin P, Green J. Susceptibility of specific tissues for metastases. In: Rubin P, Green J, eds. Solitary metastases. Springfield, IL: Thomas CC, 1968; 6. 6. Berge J, Lundberg S. Cancer in Malmo 1958-1969. An autopsy study. Acta Pathol Microbiol Scand (A) 1977; (Suppl. 260): 67-68. 7. Pellegrini AE. Carcinoma of the lung occurring as a skeletal muscle mass. Arch Surg 1979; 11: 550. 8. Sridhar KS, Ramesh KR, Kunhardt B. Skeletal muscle metastases from lung cancer. Cancer 1987; 59: 1530-4. 9. Colantuano A, Maccaurao L. Su di un caso di metastasi muscolare come prima manifestazione di un cancro del polmone. Rass Int Clin Ter 1969; 49: 568-76. 10. Shachor J, Luria H, Cordova M, Bernheim J, GrifTel B, Bruderman I. Long-term survival in bronchogenic carcinoma with a solitary metastasis. Eur J Surg Oncol 1986; 12: 7780. 1 1 . Liote F, Vigneron AM, Kahn MF, Folinais D. Dorsolombalgies revelatrices d’une metastase muscolaire paravertebrale d’un carcinoma epidermi’dale bronchique. Rev Rhum Ma1 Osteaartic 1986; 53: 552. 12. Milosvicz D. Bronchial carcinoma with metastases presenting as gluteal abscess. Plune. Bolesti Tuberk 1974; 26: 210-2. 13. Rornanathan T. Bronchial carcinoma metastases presenting as gluteal abcess. Br J Dis Chest 1973; 67: 167-8. 14. Kinsey DL. An experimental study of preferential metastases. Cancer 1960; 13: 674-6.

15. Folkman J. Tumor invasion and metastasis. In: Holland JF, Frei E, ed. Cancer medicine. Philadelphia: Lea & Febiger 1982: 167-77. 16. Wood S Jr, Baker RR, Marzocchi B. In vivo studies of tumor behavior: Locomotion of and interrelationships between normal cells and cancer cells. In: Proliferation and spread of neoplastic cells. Baltimore: Williams & Wilkins 1968; 495510. 17. Nicolson GL. Cellular interactions in blood-borne metastatic tumor spread to specific secondary sites. In: Day SB, Myers WP, Stansly P, et al., eds. Cancer invasion and metastasis: biologic mechanism and therapy. New York: Raven Press, 1977. 18. Chew EC, Josephson RL, Wallace AC. Morphologic aspects of the arrest of circulating cancer cells. In: Weiss L, ed. Fundamental aspects of metastasis. Amsterdam: North-Holland Publishing, 1975; 121 -50. 19. Kadish JL, Buttefield CE, Folkman J. The effect of fibrin of cultured vascular endothelial cells. Tissue Cell 1979; 1 1 : 99108. 20. Folkman J, Cotran RS. Relation of vascular proliferation to tumor growth. In: Richter GW, Epstein MA, eds. International review of experimental pathology. New York: Academic Press, 1976; 207-47. 21. Filder IJ, Hart IR: Principles of cancer biology, biology of cancer metastasis. In: De Vita VT, Hellmann S, Rosenberg SA, eds. Cancer, principles and practice of oncology. Philadelphia: J. B. Lippincott, 1982; 80-92. 22. Lasser A, Zacks SI. Intraskeletal muscle myofiber metastasis of breast carcinoma. Hum Pathol 1982; 13: 104-6. 23. Mulsow FW. Metastatic carcinoma of skeletal muscles. Arch Pathol 1943; 35: 112-4. 24. Sinclair DC. Muscles and fasciae. In: Romanes CF, ed. Cunninghams textbook of anatomy, ed. 12. New York: Oxford University Press, 1981: 265-8. 25. Agostino D, Cliffton EE. Trauma as a cause of localization of blood-borne metastases preventative effect of heparin and fibrinolysin. Ann Surg 1965; 161: 97-101. 26. Fisher B, Fisher ER, Feduska N. Trauma and the localization of tumor cells. Cancer 1967: 20: 23-30.

SIMULTANEOUS DISSEMINATED HERPES ZOSTER A N D BACTERIAL INFECTION IN CANCER PATIENTS The morbidity and mortality rates caused by infections are high in cancer patients (1). About half of all cancer patients have a serious infection when the granulocyte count is 100 mg/l). Acyclovir dosage was calculated according to the patient’s weight and renal clearance. The daily doses were administered as i.v. infusions and varied between 250 mg and 875 mg x 3. The duration of treatment ranged from 5 to 14 days, median time 5 days. Acyclovir cream was also applied to the involved dermatome 5 times daily. Both treatments were started immediately at the first signs of varicella infection. Acute neuritis was treated with the appropriate non-narcotic or narcotic analgesics. Empirical antibacterial treatment was started without delay when symptoms fulfilled the criteria for bacterial infection. The primary antibiotic combination was that routinely used in this department and consisted of cefotaxime or ceftriaxone plus oral ofloxacin (3, 16). The primary antibacterial treatment was changed when no clinical response was achieved according to the microbiological documentation and determination of resistance when these were available. Mucositis was treated with oral natamycin or fluconazol simultaneously with dexpanthenol solution. Lidocaine solution was administered in cases with pain during nutrition. Results. Thirteen of the 28 patients with disseminated herpes zoster had malignant non-Hodgkin’s lymphoma, 6 had breast cancer, 3 Hodgkin’s disease, and 6 another type of cancer. Clinical bacterial infection was registered in 22 patients (79%) with microbiological documentation from focuses or blood cultures in 14 patients (50%). In nine of these, infection was caused by grampositive organisms (Table). Mucositis caused by candida albicans was found in 5 patients. Septicemia was established in 13 patients, complicated infection of the urinary tract in 5, and skin infection in 4. All skin infections were microbiogically documented. All patients with grade 1 to 4 granulocytopenia and 46% of patients with grade 0 granulocytopenia developed bacterial infection. All patients recovered from bacterial and fungal infections. Complete healing of herpes zoster skin lesions was achieved in 24 patients (86%). Four patients died during the treatment with acyclovir.

Table Microorganisms isolaied in 28 cancer patients with herpes zoster

Microorganism

Patients n (YO)

Staphylococcus epidermidis Staphylococcus aureus Pseudomonas E. coli Klebsiella Enterococcus Candida albicans Total bacterial

5 (18) 3 (11) 2 (7) 2 (7) 1 (4) 1 (4)

5 (18) 14 (50)

The causes of death were stage IV breast cancer and ascites (n = I), myocardial infarction (n = I), and generalized herpes zoster (n = 2). Reactivation of lesions was noticed in the latter two cases during i.v. treatment with acyclovir. There were no adverse effects that could be directly attributed to acyclovir. Acute neuritis was present in 9 patients (32%). In one patient the pain was caused by a large abscess. In another patient with herpetic lesions involving the mouth, the pain was present during nutrition but the skin lesions were painless. Narcotic analgesics for pain due to herpes zoster were required by three patients. Discussion. During adulthood, varicella zoster virus is reactivated, causing infection. The occurrence of herpes zoster is higher than in older people, in immunocompromised individuals, and in cancer patients on anticancer chemotherapy. In the latter, infection may be very severe and even fatal. Acyclovir is suggested by some authors to be the most effective agent at present in the treatment of herpes zoster, although its effects on healing of skin lesions and on pain relief are controversial (7, 17, 18). It has also been observed that in most patients varicella zoster virus reactivates within about two years of initial treatment of Hodgkin’s disease and within one year of bone marrow transplantation (19). In these patients, chemoprophylaxis of viral infection with acyclovir may be indicated (19). In the present study, treatment with i.v. acyclovir was certainly helpful. Complete control without complication of herpetic lesions was achieved in 86% of the patients. Treatment failure, possibly related to the poor efficacy of acyclovir (or poor immunoresponse of the patient), was observed in two patients only (7%). Nine patients (32%) suffered from acute neuritis. In some other studies this has been reported to occur in 60% of patients, while almost 50% complained of pain in the involved dermatome months after disappearance of cutaneous disease (7, 8). Unlike certain previous reports in the literature (7, 8), the effect of acyclovir on pain in the present study was obvious. This could be due to the fact that the treatment was started immediately at the first signs of herpes zoster. It can be concluded from the above findings that most patients benefited from administration of acyclovir for the control of acute neuritis and postherpetic neuralgia. During the follow-up period, no patients complained of pain possibly related to herpes zoster. The direct effect of acyclovir on the healing of vesicular eruptions cannot be demonstrated conclusively but its prophylactic effect on visceral complications was apparent since there was no such case in the present study. Bacterial and fungal infections are frequent complications in cancer patients receiving antineoplastic treatment. Acute inflammatory symptoms from the urinary, gastrointestinal or

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respiratory tracts with high fluctuating fever are diagnostic signs of bacterial infection. Unfortunately, simultaneous disseminated herpes zoster infection may mask many of these signs of bacterial or fungal infections. Microbiological findings from focuses or blood cultures should perhaps be used to document bacterial or fungal infection. Immediate, empiric antibacterial treatment is one of the most important achievements in the treatment of cancer patients (20). In the present study the patients received antibacterial treatment immediately when bacterial infection became apparent. There were no cases of death or complication due to bacterial infection in these patients. Prophylactic treatment of bacterial infection and prophylactic administration of granulocyte colony stimulating growth factors are at present used in neutropenic patients in our department. However, very few studies are currently being conducted concerning prophylaxis of viral infections. Such treatment should be explored in cancer patients to establish whether it reduces morbidity and mortality and increases the efficacy of anticancer therapy with avoidance of delay of the schedule or reduction of the dose. ABDELG. MAICHE MICHAELJ. KAJANTI SEPPO PYRHONEN

Department of Radiotherapy and Oncology Helsinki University Central Hospital Helsinki Finland

June 1992 Correspondence to: Dr A. G. Maiche, Dept. of Radiotherapy and Oncology, Helsinki University Central Hospital, Haartmaninkatu 4, SF-00290 Helsinki, Finland.

REFERENCE 1. Abrahamsen AF, Borge L, Hoke H. Infection after splenec-

tomy for Hodgkin’s disease. Acta Oncol 1990; 29: 167-70. 2. Schimpff SC. Empiric therapy for granulocytopenic cancer patients. Am J Med 1986; 80 (Suppl. 5C): 13-20. 3. Maiche AG, Teerenhovi L. Empiric treatment of serious infections in patients with cancer: Comparison of two combinations. Infection 1991; 19 (Suppl. 6): 326-9. 4. Maiche AG. Use of quinolones in the immunocompromised host. Eur J Clin Microbiol Infect Dis 1991; 10: 361-7. 5. Goffinet DR. Glatstein EJ, Merigan TC. Herpes-zoster var

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cella infections and lymphomas. Ann Intern Med 1972; 76: 235-40. 6. Mazur MB, D o h R. Herpes zoster at the NIH: a 20-year experience. Am J Med 1978; 65: 738-44. 7. Shepp DH, Dandliker PS, Meyers JD. Treatment of varicellazoster virus infection in severely immunocompromised patients. N Engl J Med 1986; 314: 208-12. 8. Whitley RJ, Soong SJ, D o h R, Betts R, Linnemann C, Alford CA, NlAID Collaborative Antiviral Study Group. Early vindarabine therapy to control the complications of herpes zoster in immunosuppressed patients. N Engl J Med 1982; 307: 971-5. 9. Guinee VF, Guido JJ, Pfalzgraf KA, et al. The incidence of herpes zoster in patients with Hodgkin’s disease. Cancer 1985; 56: 642-8. 10. Crown JPA, Chahinian PA, Jaffrey IS, Glidewell OJ, Kaneko M, Holland JF. Predictors of 5-year survival and curability in small cell lung cancer. Cancer 1990; 15: 382-6. 1 I . Huberman M, Fossieck BE, Bunn PA, Cohen MH, lhde DC, Minna JD. Herpes zoster and small cell bronchogenic carcinoma. Am J Med 1980; 68: 214-8. 12. Schimpff S, Serpick A, Stoler B. Varicella zoster infection in patients with cancer. Ann Intern Med 1972; 76: 241-54. 13. Engst R. Therapy of herpes zoster. Z Hautkr 1989; 64: 848-50. 14. Haddad J, Messer J, Willard D, Ritter J. Acyclovir and pregnancy: current aspects. J Gynecol Obstet Biol Reprod (Paris) 1989; 18: 679-83. 5. Miller AB, Hoogstraten B, Staquet M, Winkler A. Reporting results of cancer treatment. Cancer 1981; 47: 207-14. 6. Maiche AG, Teerenhovi L. Empiric treatment for serious infections in patients with cancer: comparative study of two combinations comprising intravenous plus per oral antibiotics. (abstract). Berlin: ICC, 1991: 989. 7. Balfour HH, Bean B, Laskin OL. Acyclovir halts progression of herpes zoster in immunocompromised patients. N Engl J Med 1983; 308: 1448-53. 18. Prober CG, Kirk LE, Keeney RE, Acyclovir therapy of chickenpox in immunosuppressed children-a collaborative study. J Pediatr 1982; 101: 622-25. 19. Meyers JD. Chemoprophylaxis of viral infection in immunocompromised patients. Eur J Cancer Clin Oncol 1989; 25: 1369-74. 20. Klastersky J. Empiric antimicrobial therapy for febrile granulocytopknic cancer patients; lesions from four EORTC trials. Eur J Cancer Clin Oncol 1988; 24: 35-45.

Simultaneous disseminated herpes zoster and bacterial infection in cancer patients.

Acta Oncologica ISSN: 0284-186X (Print) 1651-226X (Online) Journal homepage: http://www.tandfonline.com/loi/ionc20 Simultaneous Disseminated Herpes...
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