HK J Paediatr (new series) 2017;22:179-180

A Rare Presentation of Varicella: AcuteAppendicitis

Dear Editor,

Acute appendicitis is one of the most exceptionalcomplications of varicella.1-3 We have a patient withvaricella who was diagnosed as acute appendicitis initiallyand had vesicular rash on the second post-operative day.

A previously healthy 10-year-old female was admittedto our hospital with complaints of abdominal pain lastingfor 2 days and vomiting. There was no skin lesion at firstexamination. Her abdomen was sensitive especially in theright lower quadrant. Abdominal ultrasonography revealedacute appendicitis with a diameter of 10 milimeters. Patientunderwent appendectomy. There were no fecalith detectedin gross examination. Histopathological examination of theappendix revealed neutrophilic infiltration and necrotic wallwith diffuse proliferation of lymphocytes (Figure 1). Onthe second postoperative day vesicular skin lesions werenoted on her trunk (Figure 2). Serological tests showed anti-Varicella zoster virus (VZV) IgM and IgG antibodies inperipheral blood. The patient was discharged on the thirdpostoperative day.

Acute appendicitis is the most common cause ofabdominal surgery for children. It is generally accepted

Letter to the Editor

that obstruction of the appendix lumen is the initiativecause of acute appendicitis. This obstruction might becaused by lymphoid hyperplasia, fecalith or other foreignbodies (usually seeds of fruits). Lymphoid hyperplasiawhich has developed as the result of bacterial infectionssuch as Escherichia coli, Bacteriodes fragilis, Yersinia,Salmonella or Shigella, parasitic infestation such asEntamoeba histolytica and enteric or systemic viralinfections such as Epstein-Barr virus, Adenovirus andCytomegalovirus, may cause obstruction in appendixlumen.4 Likely, lymphoid hyperplasia is seen in thepathological investigation of the appendix in our case,too. This make us think that lymphoid hyperplasia thatdeveloped during the incubation period of the infectionmay have caused acute appendicitis.

It is not possible to clearly understand the relationbetween herpes viruses and acute appendicitis. Katzoli etal5 showed viral DNA of CMV, HHV-6, EBV and HSV-1viruses in the appendectomy specimens of a group of 38children with acute appendicitis. But in their study therewere no specimen positive for VZV or HSV-2. Pogorelicet al2 reported the first case of varicella related appendicitisconfirmed by PCR evidence of VZV in appendix tissue.Our case was not diagnosed as varicella before theappendectomy operation so we fixed the appendectomyspecimen with formalin solution routinely. Maybe with this

Figure 1 Pathological investigation of the appendix. (a) Lymphoid follicle hyperplasia (H&E x10). (b) Acute inflammation ofthe appendix wall with diffuse infiltration of lymphocytes and inflammatory cells (H&E x20).

180 Letter to the Editor

Figure 2 Characteristic skin lesions in different stages of development (maculopapular or vesicular) wereseen on the trunk (Photos were obtained on the postoperative 7th day).

reason PCR analysis of appendix tissue was negative forVZV DNA in our case.

Acute appendicitis still remains an extremely rarecomplication of varicella and there are only a few casereports of acute appendicitis as a complication of varicella.1-3

In these reports the diagnosis of varicella is known beforethe operation of appendectomy. But here we describe, toour knowledge, the first case of varicella presenting withacute appendicitis.

It can be conclude that lymphoid hyperplasia which isdeveloping in the incubation period of the varicellainfection, may have caused acute appendicitis. Althoughvaricella is generally a mild infectious disease for children,it rarely may cause surgery requiring complications. Furtherstudies are necessary to understand the exact role of thevirus in the pathogenesis of acute appendicitis.

References

1. Lukši B, Mladinov S, Goi -Bariši I, Srzi A, Brizi I, Peri L.Acute appendicitis, a rare complication of varicella: a report ofthree cases. J Infect 2012;64:430-3.

2. Pogoreli Z, Bioci M, Juri I, Milunovi KP, Mrkli I. Acuteappendicitis as a complication of varicella. Acta Medica (HradecKralove) 2012;55:150-2.

3. Harvánek K, Chromcák V. Infectious diseases in childrencomplicated by appendicitis. Rozhl Chir 1990;69:538-42.

4. Rebelo Pacheco S, Rocha Brito MJ. Acute Appendicitis-AnUnexpected Etiology. J Pediatr 2016;172:221.

5. Katzoli P, Sakellaris G, Ergazaki M, Charissis G, Spandidos DA,Sourvinos G. Detection of herpes viruses in children with acuteappendicitis. J Clin Virol 2009;44:282-6.

S KILIC

A ATICI

Clinic of Pediatric Surgery,Aksaray State Hospital,

Aksaray, Turkey

A KILINCER*Radiology, Zile State Hospital,

Tokat, Turkey

G OZCIFTCI

Clinic of Pediatrics,Aksaray State Hospital,

Aksaray, Turkey

*Correspondence to: Dr A KILINCER

Email: akilincer@yahoo.com