CHICKENPOX IN A GERIATRIC PATIENT

Abstract

To the Editor: In adults, infection from varicella zoster virus (VZV) may present and be accompanied by many complications.1,2 We present a case of varicella (chickenpox) infection in an elderly patient with multisystem reactions. An 87-year-old male farmer was admitted in our department complaining of fever (up to 39°C) beginning 3 days before, vertigo, confusional state, and inability to walk. Dementia had been diagnosed 2 years before, and his grandchild had been sick with varicella 10 days earlier. Physical examination was without abnormal findings, except for his mental status. The patient was stuporous, and neurological examination revealed mixed aphasia. Electrocardiogram showed right bundle branch block and sinus rhythm. Cranial computed tomography (CT) scan revealed only leukoencephalopathy and brain atrophy. Thorax x-ray revealed infiltration of the left upper pulmonary lobe, and sputum culture was negative for bacterial infection. Laboratory examination demonstrated mildly elevated the C-reactive protein (3 mg/dL; normal range 0.8–2 mg/dL). During the second day of hospitalization, and while he was receiving antibiotic therapy for pneumonia, a diminution of the fever and a vesicular rash or of the face and upper limbs appearing simultaneously were observed. The next day, the rash had spread to the scalp and whole body (Figure 1A) without return of fever; a Tzanck smear test was performed and found to be positive; immunoglobulin (Ig) M and IgG antibodies for VZV were also found. Antiviral treatment with intravenous acyclovir 10 mg/kg three times a day for 7 days3,4 and local treatment with drying antipruritic lotion was started. The fifth day after the rash appeared, the patient presented with orchitis, and tenoxicam 20 mg/d was added to his medication. A. Vesicular rash of the crural area. B. Complete disappearance of the eruption at the follow-up examination. The 7th hospitalization day, the mental status of the patients was improved, and the neurological reexamination revealed only dementia, whereas the second cerebral CT scan was unchanged. Pulmonary x-ray revealed no infiltration. The rash had completely encrusted, and the patient returned home in good clinical condition. The patient's personal physician followed up with him regularly, and a month later a complete physical and laboratory examination was performed (Figure 1B). The results revealed the complete disappearance of the eruption and of IgM antibodies for VZV, although IgG remained positive. The human race is the only known reservoir of the VZV, and 90% of susceptible individuals (seronegative) are infected when they contact with the virus. Older people are not the virus's habitual target group. A limited number of such cases are described in the literature.1,3–6 This patient was admitted for fever and neurological defect, and the laboratory examination revealed pneumonia. Negative sputum culture and the early resolution of the infiltration after acyclovir administration were indications of varicella pulmonary infiltration.7,8 The absence of infiltration of the brain according to the cranial CT scan and the improvement in mental status after the remission of the fever could be attributed to the fever, because these findings are often observed in feverish elderly patients. Aseptic meningoencephalitis7,8 could also explain these clinical findings, although it usually develops 4 to 8 days after the onset of the rash.7,8 Furthermore, lumbar puncture9 had not been performed, because the neurologist had not judged it necessary based on physical examination clinical findings and cerebral CT scan results. Orchitis7,8,10 is a rare complication, but in this patient it was the only possible one, because it manifested a few days after the onset of the rush. The patient was treated with intravenous acyclovir from the second day of the rash, as indicated in immunocompromised patients, whereas antibiotics were administrated upon admission. Although severe morbidity and high mortality usually accompany varicella infection in older people, because of the high frequency of complications, in this case, the early administration of the appropriate treatment led to the remarkable remission and excellent outcome of the patient. Financial Disclosure: The authors have no financial support to disclose. Author Contributions: Christos Savopoulos and Martha Apostolopoulou: preparation of the manuscript, treating physician, and clinical expertise. Apostolos Hatzitolios: preparation of the manuscript, data interpretation, and clinical expertise. Vasilios Tzalokostas: data interpretation and clinical expertise. Maria Kosmidou and Maria Baltatzi: preparation of the manuscript. Georgia Kaiafa: analysis of laboratory examinations and preparation of the manuscript. Dimitrios Karamitsos: clinical expertise and director of the department. Sponsor's Role: The authors had no sponsor.