Table of Contents
Washington University Experience | PERIPHERAL NEUROPATHY | 10 INFECTION | 1 Herpes Zoster | 2A0 Case 2 History
Prologue: It is unusual to encounter active Herpes zoster dorsal ganglion lesions at autopsy since shingles rarely causes death in patients and, thus, some time may elapse before a patient with a past history of shingles comes to autopsy. In the following case, the clinical picture is nearly one of a kind in that it shows active hemorrhagic ganglionitis in a baby with disseminated zoster ----.Case 2 History ---- This two month old boy was admitted to SLCH in February 1980 with chief complaints of persistent thrush and severe chickenpox. The patient was the 7 lb. 3 oz., 42-week gestational product of a 23 year old G2Ab0 mother whose pregnancy was complicated by urinary tract infections treated with sulfa drugs and spotting, long resolved before labor. Labor itself was complicated by rupture of the membranes with the expression of meconium-stained material about 8 hours prior to delivery. At birth the baby weighed 4,880 grams. cried and breathed spontaneously. Shortly after going home, the mother noted oral thrush which she treated successfully with mycostatin and Gentian violet. Four weeks prior to the current admission a sib developed chicken pox and 7-10 days later the patient shown here developed erythematous bumps starting on the leg and then spreading very slowly over a 7-10 day period, followed by rapid spread over the entire body. On physical examination the blood pressure was 96 systolic, pulse 180, respirations 52 and temperature was 37.7 C. He was quite irritable with a rash, consisting of blisters and lesions of variable ages. He subsequently developed pneumonia and seizure activity. The skin lesions progressed in spite of cool soaks and topical antibiotics. CSF revealed 30 cells without acid, 7 (all PMNs) with acid, protein 119, and glucose 81. Treatment was started with adenine arabinoside, oral Septra, and phenobarbital for seizures. The patient continued to have seizures and attacks of apnea, necessitating intubation. Hematemesis and presumed duodenal stress perforation were accompanied by massive pneumoperitoneum. The ulcer was closed surgically and a gastrostomy tube was placed. An immunoglobulin evaluation revealed an IgG of 190 (low normal), an IgA (< 14, lower limit of assay) and an IgM level (<12, lower limit of assay). C3 was 69 (low) but C4 was 19 (WNL). A nonspecific T cell stimulation test showed no stimulation of the patient's cells. At the end of February 1980, he suffered a cardiorespiratory arrest and was unresponsive to resuscitative measures. Postmortem a diagnosis of thymic aplasia was made. I realize that this is not the typical scenario of adult herpes zoster but the pathology, albeit more extensive and severe in this case, exhibits the classic hemorrhagic ganglionitis with myelitis that may develop in some cases of Herpes zoster.
