Hemorrhagic and Ecthymatous Varicella in Immunosuppressed Adults: Report of Two Cases

Abstract

Varicella infection in immunosuppressed adults can be severe with atypical presentation of skin lesions. Hemorrhagic and ecthymatous varicella is a rare entity and can be misdiagnosed due to its atypical presentation. In its severe form, individuals with underlying cell-mediated immunodeficiency disorders have a high risk of developing multiple organ involvement associated with varicella-zoster virus infection. Here, we report two cases of primary varicella with hemorrhagic and ecthymatous skin lesions in adults receiving systemic immunosuppressive drugs for autoimmune disorders. There are only a few case reports on hemorrhagic and ecthymatous varicella. Hence, this case report highlights the atypical presentation of varicella in immunosuppressed adults, which necessitates an early diagnosis and prompt treatment as a lifesaving step.

Keywords: atypical varicella; ecthymatous varicella; hemorrhagic varicella; treatment of varicella in immunosuppressed; varicella in immunosuppressed.

Figure 1. (A) Multiple erosions with heaped up hemorrhagic crusts resembling ecthyma (white arrow). (B) Tzanck smear (100x oil immersion) showing multi-nucleated giant cells with intra-nuclear inclusion bodies (black arrow). (C) Umbilicated vesicle seen over the left forearm.

Figure 2. (A) Multiple vesicles, some of them umbilicated, seen over the face. Erosions covered with hemorrhagic crusts are also seen (white arrow). (B) Few scattered umbilicated vesicles containing hemorrhagic fluid over the palms (white arrow).