October 2001

A 10-year-old girl was admitted to the hospital for evaluation and treatment of headache, decreased activity with lethargy, poor oral intake and a painful rash on her face with a red eye. The onset was about 3 days earlier and worsening. She has also had intermittent, low-grade fevers in the 101° F-102° F range. Her past medical history is remarkable only for being born in Mexico without complications, and lived in South Texas until about 1 month before this illness, when the family moved to the Central Texas area. She has been healthy and attends fifth grade. Her immunizations are up-to-date, and she has a history of varicella as a young child.

There is some cat exposure, but no known scratches and no other animal contact. She has no known allergies, and is on no medications. There are no sick contacts.

Examination reveals a somewhat lethargic 10-year-old girl whose vital signs showed a fever of 101° F, pulse of 93, blood pressure of 111/60 and respirations of 20. Her exam was also positive for the rash on her face shown in figures 1-3, revealing a vesiculopustular rash along the V-1 (the ophthalmic division of the Trigeminal nerve) cranial nerve distribution on the left side of her face and nose and an inflamed left eye that our pediatric ophthalmologist diagnosed as keratitis. Because of her lethargy, a full sepsis workup was performed, including cerebrospinal fluid (CSF), which was all entirely normal. An electroencephalogram (EEG) was also performed and was normal.

How would you treat?

1. IV acyclovir at 60 mg/kg/day ÷ q 8 hours, and trifluoridine ophthalmic drops 5 times per day pending viral culture.
2. Oral acyclovir at 30 mg/kg/day ÷ 5 times per day.
3. Trifluoridine ophthalmic drops 5 times per day.
4. IV acyclovir at 60 mg/kg/day ÷ q 8 hours.

Answer

This is a particularly difficult problem, but one that we see occasionally. My answer in this case is #1, with the key being “pending viral culture.” There are a couple of questions that are of some concern with this case.

The first question to answer is “what is the cause?” Because of the apparent dermatomal appearance, it is tempting to assume that this is zoster, caused by varicella-zoster virus (VZV).

However, as Dr. Brunell has pointed out before, the only way to know for sure, especially with the first occurrence, is with a culture, as herpes simplex virus (HSV) infections can look the same as zoster. This knowledge impacts on the topical therapy of the eye infection. If you know it is varicella zoster, then there probably is no reason to use the topical trifluoridine, since it is known to be of no benefit. But if the infection is due to HSV, topical therapy is clearly indicated, and may be sight-saving. This is not to say that varicella keratitis should not be treated with something.

In a case like this, it seems prudent to use intravenous acyclovir at the recommended dose of 1,500 mg/meter²/day, divided q 8 hours. For most children of normal height, this works out to be about 55-60 mg/kg/day. But just as importantly, an ophthalmologist should be involved in the care. Varicella (chickenpox) and zoster (shingles) in children can be treated with oral acyclovir, but one must remember that it takes a much higher dose than do HSV infections.

The recommended oral dose of acyclovir for varicella-zoster virus infections is 80 mg/kg/day divided into 4 doses. This can obviously be difficult for children to take, and absorption is not always reliable. Therefore, immunocompromised children should always be treated with the intravenous form. Because these indications and doses are difficult to remember, I would recommend referring to the 2000 Red Book (Report of the Committee on Infectious Diseases of the American Academy of Pediatrics) for guidelines. For those of you with the Visual Red Book, there are quite a few pictures of various manifestations of varicella-zoster virus infections.

The next question to answer is “if this is HSV infection, does the patient have herpes encephalitis?” She seemed to have some mental status changes that would suggest this possibility. If that is the case, IV acyclovir is certainly indicated. The recommended dose for children beyond the neonatal period is at least 30 mg/kg/day ÷ q 8 hours. While a normal CSF and normal EEG make encephalitis less likely, it is still often a clinical diagnosis, and in this case, treatment seemed appropriate.

Of course, shingles is the clinical manifestation of reactivated VZV infection, which establishes latency in the dorsal nerve root ganglia after the primary infection (chickenpox). I have been told that shingles in children is rare. On the contrary, I have found it so common that I don’t routinely take pictures of these patients anymore because my collection has grown to be quite large enough. As in the patient presented, they frequently occur on the face (figure 4; courtesy of Dr. Bill Parry), involving the trigeminal nerve and the flank/abdominal area (figures 5, 6 and 7), but can occur along any dermatome. It is often said that if the nasociliary branch of the trigeminal nerve is involved, the tip of the nose will have lesions and there is an increased risk of the eye being involved as well. While this may not always be the case, seeing this, even in the absence on obvious eye involvement, may be enough to consider an ophthalmology consult. They can see things we can’t.

Cutaneous dissemination

I have also been told that skin lesions do not occur outside the dermatome in normal, immunocompetent children. However, the same child in figures 5 and 6 is shown in figures 8, 9 and 10 clearly showing lesions widely scattered on the patient’s body. She had no evidence of visceral involvement and her immune workup was normal. This is the second patient I have seen like this with shingles and cutaneous dissemination. One of the things I like about pediatrics is that you routinely deal with patients that can have an obviously uncomfortable condition, like a case of shingles, and still smile for the camera. Figure 11 shows another patient just prior to having plastic surgery to graft over the defect remaining after a case of necrotizing fasciitis due to a group A streptococcus infection during a case of varicella. Notice the smile. I, and most adults I know, would not be smiling with that hole in our abdomen.

The patient presented recovered and was discharged but was lost to follow-up when they moved again. As is often the case, especially with shingles, especially when the infection is into the third day, her viral cultures failed to grow. Therefore, one unresolved assumption is that this was zoster.

Heartfelt condolences

I was writing this column the week of the terrorist attacks. Like almost everyone else in this country, this affected me in a deep and profound way, and stirred those patriotic feelings that I have known before when I was still in uniform. I don’t know what our military will be doing when you read this in October, but whatever it is, I wish I were directly involved. I know many of you feel the same.

I would like to extend my personal, sincere condolences to those of you who read this column who may have lost friends or family members in the New York, Pentagon, or Pennsylvania tragedies. My daughter only recently moved from the lower side of Manhattan to Queens, but still travels into the city to work. As I did, I know many of you experienced that sick feeling in your gut until you knew that your loved one was safe and out of harm’s way. However, my heart goes out to those of you who were unable to get that reassuring news. The written word cannot describe the horrible feeling of suddenly and unexpectedly losing a loved one, especially a family member. Not being able to prepare and say goodbye leaves an especially painful scar on the heart that never heals. Please feel free to e-mail me at jhbrien@aol.com with your story or comments. I am obviously not a counselor, but I do answer all personal e-mail, and I think communication, even with someone you don’t know, can be helpful.

For Your Information:

• James H. Brien, DO, Pediatric Infectious Disease, Scott and White's Children's Health Center and Texas A&M University, College of Medicine, Temple, Texas. E-mail: jhbriend@aol.com