A 36-year-old otherwise healthy white man presented to our hospital with fever and generalized rash. Symptoms initially started with a few painless, nonpruritic “pimples” at the back of his scalp that he had noted after a haircut. Within 24 hours, the lesions spread to his face, neck, and trunk. They continued to evolve despite empiric oral cephalexin and topical mupirocin prescribed by a physician at an urgent care center. The patient felt fatigued and developed fevers that prompted presentation to the emergency department. He denied any recent sick contacts, travel, insect bites, animal exposure, or new medications. He was in a monogamous relationship with his wife. On examination, temperature was 38.78°C (101.8°F); bilateral conjunctival congestion was noted; and skin examination revealed several vesicular lesions on the face, trunk, and proximal extremities in various stages of healing, sparing the palms and soles (Figures 1 and 2). Additionally, there was generalized fullness in the neck, but no discrete masses were palpable. The remainder of the physical examination was unremarkable. Blood work revealed white blood cell count of 16,000 cells/mm3 and platelets of 56,000 cells/ mm3. Hemoglobin, liver, and renal function testing were normal. Blood cultures were obtained.
Assessment
Although the differential for this clinical presentation is wide, the presence of vesicles on an erythematous base (often described as “dewdrops on a rose petal”), particularly in different stages of evolution, heightened the suspicion for chickenpox in our patient.1 Varicella typically presents as an exanthem in different stages of evolution from macules to papules, vesicles, and ultimately, scabs.1 In most instances, clinical examination clinches the diagnosis. Interestingly, the patient confirmed history of varicella during childhood. Also, immunoglobulin G antibody against varicella zoster virus, obtained on admission, returned positive. Immunoglobulin M was negative. This supported a prior history of chickenpox. Nonetheless, given typical presentation, he was placed in contact and airborne isolation for clinical suspicion of varicella infection and valacyclovir was initiated.
Blood work on subsequent hospital days showed a marked increase in the white blood cell count. It rose to 32,480 cells/mm3 on day 3 and peaked to 63,680 cells/mm3 (differential: lymphocytes 88%, neutrophils 3%, monocytes 1%, and atypical lymphocytes 8%) on hospital day 7. Blood cultures drawn on admission remained negative. Additionally, the neck fullness seen on admission was replaced by presence of multiple discrete cervical lymph nodes. However, the skin lesions began to scab, as expected with natural evolution of chicken pox and with antiviral therapy. Given the laboratory findings and evolution of examination findings, computed tomography scan of the neck, chest, abdomen, and pelvis was obtained. Radiological imaging revealed diffuse cervical and intra-abdominal lymphadenopathy and massive splenomegaly. This confounded the clinical picture, and an alternate or a concomitant diagnosis was entertained.
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-Arpan Shah, MDa, Kanika Goel, MDb, Jeffery Uchin, MDb, Sai Krishna Patibandla, MDc, Zaw Min, MDa, Nitin Bhanot, MD, MPHa
This article originally appeared in the June 2019 issue of The American Journal of Medicine.
