Superficial gangrene of the skin in chickenpox.

Gangrene of the skin is a very rare complication of chickenpox. Barenberg and Lewis (1927) saw one example in over 2,000 children and Wishik and Bullowa (1935) saw four examples in 2,534 children with chickenpox. The condition was probably first described by Stokes (1807), but was first discussed in some detail by Jonathan Hutchinson in 1882. The latter's paper is notable for the beautiful reproduction in colour of a painting of a child with multiple areas of gangrene. Hutchinson termed the condition 'varicella gangrenosa'. Crocker (1903) described it under the heading 'dermatitis gangraenosa infantum (synonyms varicella gangraenosa, pemphigus gangraenosa, rupia escharotica, echthyma terebrant, echthyma gangrenosum)'. In most of the cases described the gangrene occurred around one or more of the chickenpox lesions (Hutchinson, 1882; Crocker, 1903; Barenberg and Lewis, 1927; Rundle, 1929; Apert and Goldberg, 1930; Lavergne, Helluy and Bolikowska, 1938; Joe, 1947). In the majority of cases described the lesions were multiple, but in both Storrie's cases (1914) there was a single gangrenous area. In almost all the cases described the gangrene developed between the fourth and seventh day of the eruption. Views as to the aetiology ofthe condition are varied. Hutchinson (1882) held that it was due to an individual susceptibility to varicella, a view with which Barenberg and Lewis (1927) and Stoesser and Lockwood (1938) agreed. Schamberg and Kolmer (1928) regarded the condition as non-specific, stating that slar manifestations may occur in vaccinia, variola, scarlatina and various dermatoses. Several workers, for example, Schamberg and Kolmer (1928), Rundle (1929) and Joe (1947), thought that it occurred largely in weakly and malnourished children, many of them with tuberculosis, though other workers were impressed by the good general condition of affected children, for example, Dykes (1927) and Barenberg and Lewis (1927). Several workers ascribed the complication to secondary infection. Krjukoff (1899), Goodall (1928) and Joe (1928) described cases from which the Klebs-Loeffler bacillus was isolated. Banks and McCartney (1937) isolated the haemolytic streptococcus of Griffith Type 23 from lesions in their case, and ascribed the infection to an associated tonsillitis from which the same organism was recovered. Storrie (1914) obtained Staphylococcus pyogenes from his two cases. Nichols (1934) isolated the same organism from a case with superficial gangrene of the abdominal wall following infection of a vesicle. Gillespie and Porter (1952) described the occurrence of cellulitis or gangrene in three members of one family-the mother and two children: the lesions had to be incised and drained. In three of the cases described by Wishik and Bullowa (1935) the gangrene was preceded by celiulitis and high fever. In some cases there was an associated thrombocytopenic purpura (Stoesser and Lockwood, 1938); Batch and Sepkowitz, 1952). In most of the studies in the literature there is no record of a platelet count. Watson (1934) commented on the ecchymosis surrounding the gangrenous area in his case. Almost all writers emphasized the grave toxaemia experienced by their patients (Hutchinson, 1882; Storrie, 1914; Barenberg and Lewis, 1927; Dykes, 1927; Gordon, 1927; GoodalL 1928; Nichols, 1934; Watson, 1934; Banks and McCartney, 1937). Most of the patients described by the above writers died. Storrie collected 43 cases from the literature, 29 of which died. On the other hand one of the patients described by Wishik and Bullowa (1935) was never ill, though he developed gangrene of all the fingers of one hand, the dorsum of one foot, and part of both legs. New areas of gangrene developed 16 days after the first. Schamberg and Kolmer (1928) described the occurrence of mild cases. Dykes (1927), Watson (1934), Wishik and Bullowa (1935) and others noted the mildness of the initial chickenpox. The patient described by Dykes, for instance, had no more than 20 vesicles in all.