Case history
Case history #1
A 6-year-old boy presents with fever, headache and a diffuse, pruritic, vesicular rash, which is most prominent on the face and chest. He has had generalized malaise and low-grade fever for a few days prior to presentation. He developed high fever and a rash in the last 48 hours. Physical examination demonstrates a temperature of 102°F (39°C) and heart rate of 140 beats/minute. He has a few scattered vesicular lesions in his oropharynx and his lung fields are clear. The lesions are prominent on the face and chest, but all extremities are also involved. In some areas the lesions are crusted, while in others they appear newly formed. He has no nuchal rigidity or other meningeal signs. The child has never been vaccinated for varicella, and a classmate at his school had chickenpox a few weeks ago.
Case history #2
A 36-year-old man undergoing chemotherapy for non-Hodgkin lymphoma presents with fever, shortness of breath, hemoptysis, and a diffuse rash. His family recalls that he had a fever the previous day, and that the rash started on his chest and progressed rapidly. In a review of recent exposures, his wife recounts that she was told that a child who visited their home later developed “chickenpox.” His current medications are levofloxacin and an antidepressant. A review of his medical history indicates negative serologic tests for varicella-zoster virus prior to starting chemotherapy, and his family does not recall him receiving the varicella vaccine. On examination he has a temperature of 104.2°F (40.1°C), a heart rate of 145 bpm, and an O2 saturation of 83%. Lung exam demonstrates bilateral crackles, and the patient has diffuse vesicular lesions, some of which appear to be hemorrhagic. Initial laboratory testing indicates a low hematocrit and platelets, a low absolute lymphocyte count (<100 cells/mL), and mild transaminitis. A chest x-ray demonstrates ground glass opacities or diffuse small nodular infiltrates.
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