CLINICAL AND LABORATORY OBSERVATIONS Bullous Herpes Zoster in a Child With Leukemia Case Report and Review of the Literature Motti Haimi, MD,* Myriam Weyl Ben-Arush, MD,* Imad Kassis, MD,† Sergey Postovsky, MD,* Zipi Kra-Oz, PhD,‡ and Ronit Elhasid, MD* Abstract: Blistering disorders in childhood are usually difficult to diagnose and pose complicated management dilemmas. The inci- dence of herpes zoster in children with malignancy and immunodefi- ciency is greatly increased compared to normal children of compa- rable age. Although herpes zoster is known to occur in children with malignancy, the bullous form of herpes zoster is rare; to the authors’ knowledge, there was no previous report of this phenomenon in chil- dren in general and in children with cancer in particular. The authors describe a 3.5-year-old girl who was diagnosed with acute lympho- blastic leukemia; 7 months after presentation, during chemotherapy treatment, she developed the bullous form of herpes zoster on her right hand. The authors describe the method of diagnosis and provide a review of the literature concerning this rare phenomenon. Recog- nizing this entity and differentiating it from other bullomatous condi- tions enable the application of appropriate treatment, without unnec- essary delay. Key Words: bullous, herpes-zoster, acute lymphoblastic leukemia (J Pediatr Hematol Oncol 2004;26:587–590) A 3.5-year-old girl presented to our hospital with a 1-month history of leg pain and refusal to walk. Neurologic exami- nation revealed flaccid weakness of the lower muscle girdle, intense tendon reflexes, and pathologic Hoffman and Babinski signs. The results of blood analyses were normal except for anemia (hemoglobin, 9.2 gr%). Magnetic resonance imaging of the spine revealed abnormal signal in the lower spine. The child was diagnosed with a myelopathy (autoimmune m/p) and treated with steroids. Several days later, she developed pancy- topenia (hemoglobin, 6.8 gr%; platelets, 28,000/mL; white blood cell count, 3,800/mL), and eventually blasts appeared in the peripheral blood (27%). Bone marrow aspiration revealed acute lymphoblastic leukemia, CALLA positive, and treat- ment was administered according to the BFM-95 protocol. In- duction chemotherapy included prednisone, vincristine, and daunorubicin as well as asparaginase. The child started to stand and walk 3 weeks after beginning induction therapy. Seven months after admission, during the first part of the consolidation phase of treatment, which included vincristine, doxorubicin, L-asparaginase, and dexamethasone, the patient was admitted with fever and neutropenia. She complained of a “burning” pain along her right forearm. Several vesicles, less than 5 mm in diameter, were noticed on the first, second, and third fingers of her right hand, with a few vesicles on the right elbow. The distribution of the vesicles was compatible to der- matomes C6, C7, and T1. No other areas were involved. A general physical examination was otherwise normal. Her par- ents confirmed a history of chickenpox in the past. The child was not treated with any topical drug that could cause irritant or contact dermatitis. A diagnosis of herpes zoster was sug- gested, and treatment with intravenous acyclovir (500 mg/m 2 tid) was immediately administered, as well as intravenous cefepime due to fever and neutropenia. Despite this treatment, the vesicles rapidly enlarged, un- til a large bulla formed in the palm of the right hand. The bulla increased gradually in size over the next 4 days to a maximal diameter of 8 cm, causing pain and bluish discoloration of the fingertips. Over the distal phalanges of the first, second, and third fingers the skin became bluish-purple, without a change in the temperature of the skin. There were also some areas of purple discoloration of the skin over the proximal interphalan- geal joints of fingers 2, 3, and 4 of the right hand. There was some pallor over the rest of the hand (Figs. 1 and 2). There was no paresthesia, paresis, or pulselessness of the right hand. Al- though there were only a few signs of impending compartment syndrome, we decided at that point to puncture the bulla in a sterile setting. The bulla contained yellowish fluid, which was sent for serologic and bacteriologic examinations. This fluid was sent also to a virology laboratory. We used nested polymerase Received for publication April 17, 2004; accepted July 8, 2004. From the *Department of Pediatric Hemato-Oncology, Meyer Children’s Hospital, Rambam Medical Center, Haifa, Israel; †Infectious Diseases Unit, Meyer Children’s Hospital, Rambam Medical Center, Haifa, Israel; and ‡Virology Laboratory, Rambam Medical Center, Haifa, Israel. Reprints: Dr. Motti Haimi, Department of Pediatric Hemato-Oncology, Meyer Children’s Hospital, Rambam Medical Center, POB 9602, Haifa 31096, Israel (e-mail: morx@netvision.net.il). Copyright © 2004 by Lippincott Williams & Wilkins J Pediatr Hematol Oncol • Volume 26, Number 9, September 2004 587