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A clinical study on varicella zoster virus infection and treatment in children with malignant lymphoproliferative disease.

Journal of the Korean Pediatric Society 1991;34(9):1246-1254.
Published online September 30, 1991.
A clinical study on varicella zoster virus infection and treatment in children with malignant lymphoproliferative disease.
Hak Won Kim, Jae Won Oh, Sung Hee Oh, Ha Baik Lee, Hahng Lee
Department of Pediatrics, College of Medicine, Hanyang University, Seoul, Korea
소아 악성 임파증식성 질환에서의 Varicella Zoster Virus 감염과 치료에 관한 임상적 연구
김학원, 오재원, 오성희, 이하백, 이항
한양대학교 의과대학 소아과학교실
Received: 28 February 1991   • Accepted: 18 June 1991
Vaircella Zoster Virus (VZV) infection is usually a benign disease in normal hosts, but it is known to result in high risk for visceral dissemination and mortality in immunocompromised hosts, as in the children with malignant diseases, especially with malignant lymphoproliferative diseases. Therefore, passive or active immunization and antiviral therapeutic modality have been tried to control visceral dissemination and thus to decrease mortality in these patients. But until recently, the VZV infections in many Korean children with malignant diseases resulted in deaths according to the unpublished personal communications with many institutions in Korea. Among the total of 86 children with malignant lymphoproliferative diseases treated during the period of 5 years and 5 months from January, 1985 to May, 1990 at the Department of Pediatrics, Hanyang University Hospital, Seoul, Korea, 15 cases of VZV infections were observed. Eleven out of the 15 cases were hospitalized and treated with Acyclovir (Zovirax I.V. manufactured by Wellcome) at the dose of 500 mg/m2/dose intravenously three times daily every 8 hours for more than 6 days. The 15 cases with VZV infections were studied for their underlying malignant diseases and the disease status, the types of VZV infections and their clinical courses with the treatment outcome. The results of the study were as follows: 1) Among the total of 86 children with acute lymphoblastic leukemia (ALL) in 65, non-Hodgkin’s lymphoma (NHL) in 9 and Hodgkin’s disease (HD) in 2, 15 cases of VZV infections were observed during the study period of 5 years and 5 months. The underlying dieseases of the 15 cases were ALL in 13, HNL in one and HD in one. ALL 15 cases were in complete remission status at the time of VZV infections, with 14 out of 15 still on maintenance chemotherapy and one off chemotherapy, at 2 months to over 4 years since the diagnosis of their underlying malignant diseases. The types of VZV infections were chickenpox or varicella in 8 cases and herpes zoster in 7. Mean age was 8.1 years with the age ranging from three to 16 years, and nine out of the 15 were males. Out of the 15 cases, 11 were hospitalized at the early active phase of VZV infections and were treated with Acyclovir intravenously, bur the remaining 4 cases were outpatients whose VZV infec- tions were diagnosed rather too late for Acyclovir therapy, either mild and recovering already or almost fully recovered at the time of diagnosis, all 4 recovering spontaneously without therapy. 2) As for the 11 cases hospitalized and treated, the mean duration of eruption prio to the hospitali- zation was 2.5 days, ranging from 1 to 5 days. The mean duration of Acyclovir therapy was 7.9 days, ranging from 7 to 14 days. The mean duration of continuous eruption of new pox lesions on therapy was 3.6 days, ranging from 0 to 7 days. And the mean duration till complete crusting was 7.7 days in 9 cases and was unclear in 2 cases. 3) As for the visceral involvement, four out of the 11 cases had suspected to have varicella hepatitis with elevation of liver enzymes, AST, ALT and/or LDH, normalizing subsequently after the therapy. None out of the 11 cases developed clinical evidence of varicella pneumonitis or CNS involvement, and none died of VZV infection. 4) Five out of the 11 cases had absolute lymphocyte count (ALC) below 500/mm3, and three out of the 4 cases with suspected varicella hepatitis were among these 5 cases with ALC below 500/mm3. In conclusion, all 15 cases survived VZV infections in spite of the immunocompromised states secondary to their underlying malignant lymphoproliferative diseases and their anticancer chemother- apy, eleven out of 15 cases with Acyclovir therapy and four remaining cases spontaneously without therapy. Four out of the 11 cases treated were observed to have elevation of liver enzymes, suggesting probable varicella hepatitis, but none developed pneumonitis or CNS involvement. Absolute lymphocytopenia might result in high risk for visceral involvement or at least for varicella heaptitis. Acyclovir tlierapy was well tolerated and no significant adverse reaction to Acyclovir was observed.
Key Words: Varicella zoster virus, Acyclovir

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