Herpes virus induced bullous lesions in a child with acute leukemia

Abstract

Immunodeficient children are at a risk for development of atypical or extended infection with viral agents, including herpes virus (herpes simplex and herpes zoster). We report a 5-year-old child with B lineage acute lymphoblastic leukemia on chemotherapy with herpes virus induced atypical skin manifestations. Diagnostic possibilities of early toxic epidermo-necrolysis, staphylococcal scalded skin syndrome, pemphigus vulgaris, bullous pemphigoid, and bullous herpetic infection were kept and management with antibiotics, anti-viral, and supportive measures were ensued. Tzanck smear was negative, but skin swab grew methicillin sensitive Staphylococcus aureus. Herpes viral etiology could be established only after the skin biopsy and histopathological examination showed multinucleated cells with intranuclear inclusion body. There was no other systemic involvement except the asymptomatic elevation of transaminases. She was recovered completely with acyclovir therapy for 14 days. Our case highlights the need for heightened awareness among the clinicians for such atypical presentation of common infections in immunodeficient children, as early and prompt institution of therapy can be lifesaving. Though Tzanck smear is a good modality for the diagnosis of herpetic lesions, it should be supplemented with other diagnostic tests and should not be relied upon in isolation to refute the diagnosis.