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ABSTRACT
Objective: This research aims to describe the profile, clinical course, treatment and outcome of varicella
in immunocompromised children at the Philippine General Hospital from January 1999 to December
2004 Study Population: All immunocompromised patients less than 19 years of age with a clinical
diagnosis of varicella admitted at the Philippine General Hospital during the study period were included.
Method: A review of medical records and monthly census reports of the Pediatric Infectious
Disease and Hematology-Oncology Services was conducted.
Results: Out of 26 immunocompromised patients who developed varicella during the study period, only
22 charts were available for review. Of these patients, 13 were male and 9 were female. The highest
incidence occurred from 0 to 5 years old (41%). Twenty patients had an underlying malignancy in the
form of leukemia (14%) and solid organ tumors (6%). Two patients were on chronic steroid therapy
(Prednisone) for more than a month due to Nephrotic Syndrome and Myelodysplastic Syndrome with
Stevens-Johnson Syndrome. The most common presenting symptom was a rash (68%), with an
associated fever seen in 54% of the cases. Majority were treated with acyclovir for an average of 7
days with good response. Nine patients developed complications: mainly, pneumonia and sepsis.
Recovery rate was 82%; however, fatality rate was 13.6%.
Conclusion: Varicella in immunocompromised children is associated with increased morbidity
and mortality. Our patients responded well to sequential intravenous and oral acyclovir. Vaccination
of targeted populations such as close household contacts of immunocompromised patients, as well
as, healthcare workers may be a good strategy to protect high-risk children from developing the
disease and its complications.
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was not given any treatment because his discharged in improved condition after 8
parents decided to bring him home against hospital days.
medical advice. This was an 11-year old boy 15 patients received, both intravenous and oral
with brainstem glioma and dysautonomia, who Acyclovir, at the same dosages mentioned
nd
developed varicella on his 82 hospital day. He earlier for an average total duration of 7 days;
was also treated with multiple antibiotics for two with the exception of 1 patient who completed
bouts of gram negative nosocomial sepsis. 14 days of therapy (2 doses IV and the rest
oral) because she still had fresh lesions upon
Table 8. Distribution of subjects as to discharge. IV Acyclovir was given for an
Laboratory Tests done average of 3.6 days (range, 1 dose to 5 days)
Laboratory Tests No. % before switching to the oral form to complete 7
days. Prophylaxis with varicella-zoster immune
Blood Culture 13 59.1 globulin (VZIG) was not administered to any
Negative / no growth 9 40.9 patient. Other medications given included an
oral antihistamine for pruritus, as well as, IV
Klebsiella pneumoniae 1 4.5
antibiotics and antifungal agents to treat
Alkaligenes faecalis 2 9.1 complications that may or may not be
No information 1 4.5 associated with varicella.
Urine Culture 7 31.8 Of the 22 children hospitalized for varicella,
Negative / no growth 5 22.7 13 or 59% of them received both Acyclovir
and antibiotic therapy, while 2 or 9.1%
Candida albicans, 1 4.5
received antifungal agents as well. The
Haffnia alvei antibiotics prescribed most frequently were -
Klebsiella, Proteus 1 4.5
lactams (12 children), aminoglycosides (8
Other Laboratory Tests children) and Ciprofloxacin (3 children). The
Chest x-ray (pneumonia) 4 18.2 mean duration of antimicrobial therapy in
Tzanck smear negative 1 4.5 hospitalized patients was 6.9 days.
Outcome
ETA CS (+)
Nine patients (40.9%) developed
Pseudomonas, 1 4.5
complications, mainly pneumonia (18.2%) and
Acinetobacter
CSF (-) 1 4.5 sepsis (9.1%). Secondary bacterial infection of
the skin and cellulitis was noted in one patient
each. Disseminated disease with multiple
Three patients were given intravenous (IV) complications was seen in 3 patients (13.6%), 2
2 of whom were mortalities: a 9-year old boy with
acyclovir at 500 mg/m /dose given as a one-
hour infusion every 8 hours; but only one ALL who developed pneumonia, oral thrush,
patient completed the 7- day IV therapy. sepsis, and a bleeding diatheseswhich led to
3 patients were given oral acyclovir at 60-100 his demise; and a 6-year old boy with
mg/kg/day, 4 to 5 times a day, for 7 days. These embryonal rhabdomyosarcoma and pulmonary
patients were started on the oral form due to tuberculosis, who developed pneumonia with
financial constraints. Of these 3 patients, one pleural effusion and cellulitis of the right neck,
developed a varicella-associated complication, and eventually died of septic shock. The third
i.e. an 11-year old boy with Acute Myelogenous patient was a 16-year old male with ALL, who
Leukemia, who developed infected skin lesions. developed pneumonia and hepatitis but
He was treated with intravenous Oxacillin for 7 recovered from these complications and was
days and was sent home improved after 11 hospital days.
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Patients who developed pneumonia were chickenpox and zoster than those with B-
diagnosed clinically and radiographically. cell abnormalities. These children are also,
Sepsis with systemic inflammatory more likely, to be hospitalized for antiviral
response occurred in 2 childrenboth of treatment and observation.
whom had negative blood culture results. Table 9. Association of variables with the
There was no significant association development of complications
Variable With Without p-
among age, sex, and underlying Complications Complications value
immunocompromised state of a patient and No. (%) No. ( %
the development of complications. Neither Age in 0.439
could a relationship between laboratory years
features and the development of varicella- 0-5 4 44.4 5 55.6 (NS)
associated complications be established, 6 - 10 2 50.0 2 50.0
given the small sample size (Table 9). 11 - 15 2 33.3 4 66.7
16 - 19 1 33.3 2 66.7
Duration of hospitalization due to varicella
Sex 0.439
alone was 7.96 + 3.57 days (range, 2 to 20 Male 6 46.2 7 53.8 (NS)
days), but the total duration of hospital stay was Female 3 33.3 6 66.7
18.36 + 19.25 days (range, 2 to 83 days). Underlying Disease or Immunocompromised 0.338
Majority of patients were confined for more than State (NS)
a week, after resolution of varicella: either for Cancer 9 45.0 11 55.0
continuation of chemotherapy or treatment of a Chronic 0 0.0 2 100.0
Steroid
nosocomial infection. Therapy
Three patients died with a case fatality rate WBC Count*(109/L)
of 13.6%. Recovery rate was 81.8%. (Table 10) <5 4 44.4 5 55.6
5 - 10 x 2 25.0 6 75.0
DISCUSSION > 10 x 3 60.0 2 40.0
Differential Count
From 1999 to 2004, 26
PMN *
immunocompromised children were < 0.50 3 33.3 6 66.7
hospitalized for varicella at the Philippine 0.50 - 3 60.0 2 40.0
General Hospital. 24 of these patients had 0.70
underlying malignanciesgiving an incidence > 0.70 3 37.5 5 62.5
rate of 0.53% (range, 0 to 1.14%). This Lymphocytes *
approximates that of Feldman and Lott in a < 0.20 6 54.5 5 45.5
study of 288 American children with cancer 0.20 - 2 33.3 4 66.7
0.40
covering a 24-year period, where the annual
> 0.40 1 20.0 4 80.0
incidence of chickenpox was noted to vary
6 Absolute Lymphocyte Count *
from <0.5% to 2%. 0- 4 66.7 2 33.3
The most common primary disease or 500
immunocompromised state was Acute 501 1 33.3 2 66.7
Lymphoblastic Leukemia (ALL); and 30% (6/20) 1000
> 1000 4 30.8 9 69.2
had solid organ tumors. It has long been
presumed that cell-mediated immunity (CMI) p value < .05 statistically
plays a greater role both for limiting the extent of significant NS not significant
primary infection with varicella-zoster virus and for * Statistical test cannot be performed
preventing reactivation of virus with herpes due to very low frequencies
11, 12
zoster. Children with impaired CMI, such as
those with leukemias and solid tumors are, thus,
more likely to develop disseminated
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Table 10. Duration of Hospital Stay and Outcomes 2 patients were receiving corticosteroids for
of Treatment of Varicella more than a month, prior to the development of
Duration of Hospital Stay No. %
varicella. Foreign studies have shown that
Hospital Stay Due to 7.96 3.57
Varicella severe varicella infections with fatal
1 week or less 9 40.9 complications were noted in children receiving
corticosteroids despite the administration of
more than 1 week 13 59.1 25
varicella-zoster immune globulin (VZIG).
Total Duration of Hospital 18.36 19.25
Stay Systemic corticosteroid therapy is said to
1 week or less 4 18.2 increase morbidity, even in patients without
more than 1 week 18 81.8 other conditions, especially when administered
12
Outcome of Treatment No. %
during the incubation period of varicella.
Although these 2 patients were receiving oral
Recovered 18 81.8
prednisone at dosages of less than 2 mg per kg
Home against advice/per 1 4.5 body weight per daythe dose which has been
request thought to be safe, some studies have
Died 3 13.6 suggested that even smaller dosages may
Intracranial hemorrhage 1 4.5 place patients at increased risk for severe
13
Disseminated intravascular 1 4.5 varicella. Fortunately, neither of the 2 patients
coagulopathy 2o to sepsis in this study developed varicella-associated
Septic shock 1 4.5 complications.
In this study, 18 children (90%) were on Children less than 5 years of age
immunosuppressive chemotherapy comprised the bulk of admissions. They were
(methotrexate, mercaptopurine, prednisone, likewise observed to develop complications
etc.) for 2 weeks (mean 17.5 + 11.62 days) more than any other age group, which was
before the development of varicella; and were similar to the local study of Yason. This is not
mostly on the maintenance phase. 4 out of 6 surprising because in general, children who
children in the induction phase and 5 out of 11 belong to this age group are said to be the
children in the maintenance phase of anticancer most vulnerable to infectious diseases in
treatment developed complications. This implies terms of morbidity and mortality.
that the more severe the immunosuppression, Varicella is highly contagious. Secondary
the greater the risk of developing varicella- attack rates among susceptible household
associated complications. Indeed, Feldman and contacts of persons with varicella are as high as
Lott noted that children who had successfully 90% (i.e., 9 out of 10 susceptible household
completed chemotherapy for cancer, but contacts will become infected).15 In this study,
developed varicella, had a clinical course that only 2 children had a known exposure to
was uncomplicated and similar to otherwise siblings in the household who developed
normal healthy children. None of these children chickenpox. No subjects were exposed to
had received chemotherapy or irradiation for 30 varicella in the schools perhaps because none
days to 9 years. In contrast, VZV pneumonitis of them were currently attending school due to
was noted to develop in 29 out of 103 children their immunocompromised state. Majority
who received chemotherapy 3.3 + 5.0 days (18/22) had no known exposures; similar to a
6 study done by Buda and colleagues among
(range, 0 to 15 days) before the infection.
children with ALL, who developed varicella
Unfortunately, in our study, too few subjects
infection, but with half of the cases occurring
with the infectionduring different phases of
without a known exposure.16 This implies the
anticancer treatment, were available for likelihood of community-acquired varicella as
assessment of outcome. the major source of infection for
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