IN REPLY: VARICELLA AND NECROTIZING FASCIITIS

Abstract

We thank Dr. Rosefsky for his letter concerning our previously published article.1 He correctly notes that in a partially overlapping group of patients with varicella and invasive group A streptococcal (GAS) disease in Seattle, 92% received acetaminophen and 75% received ibuprofen at some point after the onset of chickenpox. He makes three observations: (1) several of the above patients received ibuprofen after signs suggestive of secondary GAS infection developed; (2) there are quotes from the pediatric literature suggesting that ibuprofen may be superior to acetaminophen in relieving prodromal or constitutional symptoms of varicella; and (3) GAS necrotizing fasciitis complicating varicella is an old disease and its apparent resurgence may be a byproduct of referral patterns and media attention. As to the final observation we can only offer that our tertiary care institution has managed some 18 patients with GAS necrotizing fasciitis in the last 3 years,2 compared with an average of one case every 2 years during the previous decade, and we refer to recent literature review.3 As to the other observations our article specifically reported only those medications administered after the initial signs of secondary GAS infection developed. The concern over the effectiveness of ibuprofen or other nonsteroidal medications (NSAIDs) in alleviating symptoms associated with primary varicella and over the suppression by acetaminophen of neutralizing antibodies to rhinovirus were not germane to our discussion of the recognition or treatment of necrotizing fasciitis. Although we noted that previous investigators have associated NSAIDs with accelerated courses of necrotizing fasciitis or impairment of phagocytic function in vitro (see review4), our discussion focused on the problem of delayed diagnosis of GAS necrotizing fasciitis, which continues to be a potentially fatal infection. Indeed, it is precisely the unique clinical effectiveness of NSAIDs and their administration after the onset of potential indicators of secondary GAS infection that gives us greatest pause. We found the presenting signs and symptoms of GAS necrotizing fasciitis in children with primary varicella included pain, swelling, and fever beyond the first 3 or 4 days of exanthem. These findings are confirmed in an other series of 24 patients with a variety of invasive complications of primary varicella.5 If a child with varicella presents with marked soft tissue findings, toxic or lethargic appearance, hypotension and tachycardia, the decision to admit for intravenous antibiotics and immediate surgical evaluation is straightforward. When the child appears generally well but complains of localized pain or develops late fever, the pediatrician's clinical judgment becomes paramount. A blood culture and careful observation for progression of symptomatology are essential. Administration of analgesic, antipyretic or antiinflammatory medications may suppress the most important clinical findings of advancing GAS soft tissue disease,6 obfuscating the diagnosis, especially in those children followed as outpatients. Comforting patients is a primary duty of the physician, but comfort in the face of uncertainty or ignorance can be profoundly dangerous. We strongly reaffirm our original statement in our article that it may be prudent to limit the use of NSAIDs in children with localized complications of varicella until invasive bacterial disease has been excluded from the differential diagnosis. Thomas V. Brogan, M.D.; Victor Nizet, M.D.; John H. T. Waldhausen, M.D.; Craig E. Rubens, M.D., Ph.D.; William R. Clarke, M.D. Children's Hospital and Medical Center Seattle, WA