Case 184. Varicella, hemorrhagic (15 y-o M)
         
    Hemorrhagic vesicles on the trunk, face and head in case of acute leukemia after bone marrow transplantation (biopsy from the trunk)    
         
   
Key words : varicella-zoster virus, hemorrhagic varicella
   
         
   
opportunistic infection
   
     
 
     
Hemorrhagic (atypical) varicella is a lethal systemic infection of VZV, seen in the immunocompromised host. The vesicles are hemorrhagic and irregular-shaped. The hair has been lost because of treatment.   The acantholytic squamous cells possess nuclear inclusion bodies with groundglass appearance. Multinucleation is associated (HE). The vesicles in common varicella and herpes zoster never show hemorrhagic change.
     
 
     
Immunostaining using monoclonal antibody to GP-1 antigen of VZV shows plasma membrane staining on the infected cells. Nuclear inclusions are not stained.   Immunostaining using a 1:500 diluted serum from another adult patient suffering from varicella discloses the membrane reactivity. GP-1 antigen is known to be highly immunogenic.
     
 
     
A non-vesiculated infection focus seen at the periphery of the hemorrhagic vesicle. Viral inclusions are evident (HE).   Capillary endothelial cells in the upper dermis are infected. Nuclear inclusions of Cowdry's type A can be seen in the multinucleated cells (HE). This reflect the systemic dissemination of the virus.
     
 
     
Reference case 184A
Multifocal herpes zoster seen in case of Hodgkin's lymphoma after extensive chemotherapy. At autopsy, systemic infections of VZV were identified. Infection in the inflamed celiac ganglion is shown here (HE). Multifocal or bilateral occurrence of herpes zoster represents opportunistic reactivation of VZV. In this case, disseminated necrotic lesions are seen in a variety of internal organs. Refer to case 15.
  Reference case 184A
Phloxine-tartrazine stain for inclusion bodies. The intranuclear inclusions are stained red (phloxinophilic). This classic staining method can now be replaced by immunostaining employing specific antibodies.