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EXPERIENCE AND REASON:
Dan Kouwabunpat, Jill Hoffman, and Robert Adler
Varicella Complicated by Group A Streptococcal Sepsis and Osteonecrosis
Pediatrics 1999; 104: 967-969 [Abstract] [Full text] [PDF]
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eLetters published:

[Read eLetters] Varicella complicated with bone-marrow aplasia
Cecilia Oliveira Barbosa   (18 October 1999)
[Read eLetters] Pre-disposing Factors
William V La Via   (11 November 1999)

Varicella complicated with bone-marrow aplasia 18 October 1999
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Cecilia Oliveira Barbosa,
resident doctor - Pediatrics
Federal University of Rio de Janeiro - Brazil

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Re: Varicella complicated with bone-marrow aplasia

cecilia.o.b{at}uol.com.br Cecilia Oliveira Barbosa

Dear Dr.Kouwabunpat,

we have been recently surprised with a 3 y 7 m-old-boy who presented with Varicella (with just a few skin lesions) and some five days latter became pancytopenic - the bone-marrow biopsy was diagnostic of bone-marrow aplasia.

He was a previously healthy boy, and what brought us to a point was that he had clinical purpura (echimosis, petequial rash) about a week before the skin lesions (varicella) showed out. His mother had had varicella some three weeks before.

The disease began about 2 months ago, and although the bacterian infection (sepsis) is apparently under control, he still has some skin lesions (hematic crosts) and is still in bone-marrow aplasia.

We searched the medline for similar cases but we've found only two abstracts which mentioned this association (varicella X pancytopenia). Have you ever seen this before?

I'm looking forward to hearing from you.

Yours sincerely, Cecilia Oliveira Barbosa

Pre-disposing Factors 11 November 1999
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William V La Via,
Physician
University of South Florida

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Re: Pre-disposing Factors

laviaw{at}allkids.org William V La Via

Much attention has been focused recently (including an April article in this journal) on the possible increased risk for severe group A strept infection after NSAID usage in varicella. The case report does not specify whether this patient had prior NSAID usage or not. Is this information available? If so, was ibuprofen used prior to admission?

Also, no comment is made about whether these isolates were exotoxin producers or not. If the isolates are still available they should be evaluated for streptococcal exotoxin A production. Acute and convalescent titers for this exotoxin might further support it's role in this dramatic presentation if they were suggestive of exposure. Although this is an interesting case, with these additional data we might be able to better understand the reasons for this complication.