Lesson of the Week: Near fatal chickenpox during prednisolone treatment

Abstract

Case report We admitted a 27 year old woman with a 36 hour history of severe lower back pain. She had been taking steroids for six weeks; she started taking prednisolone 60 mg daily for idiopathic thrombocytopenia, but for the two weeks before admission she had been taking 30 mg daily. Twenty four hours after admission she developed a fever of 37.8°C and a maculopapular eruption with vesicles over the neck and shoulders. Vesicular fluid contained herpes virus particles, and we confirmed varicella zoster virus by immunofluorescence. The patient had not had chickenpox before, but she had been in contact with fellow students from her college, where there had been a number of recent cases. We started treatment with intravenous acyclovir 10 mg/kg three times daily immediately after diagnosis. We reduced the dose of prednisolone to 20 mg daily and gave intravenous immunoglobulin to correct the thrombocytopenia. During the next 24 hours the rash became much more extensive and some lesions became haemorrhagic. Sixty hours after admission the patient was breathless and confused, with an arterial oxygen saturation of only 70%. A chest x ray film showed bilateral alveolar shadowing. A radiograph taken 24 hours earlier had been reported as normal. We transferred the patient to the intensive care unit, where, later that evening, artificial ventilation became necessary. She was found to have rapidly progressive disseminated intravascular coagulation, renal failure (creatinine concentration 220 μmol/l), and hepatitis (alanine transaminase concentration 6700 IU/l). In addition, she developed vitreal haemorrhages with bilateral acute retinal necrosis. After two weeks in intensive care she made a good general recovery, but, although the retinal necrosis improved considerably, she was left with poor colour vision and permanent perimacular scotomas. She has, therefore, been unable to pursue her chosen career as a knitwear designer. Nevertheless, apart from the visual problems, she was completely well and receiving no treatment 12 months after the illness.