Infections may be accompanied by cutaneous manifestations (see Chapter 94 Infectious Disease Emergencies ) Although not unique to oncology patients, certain infections affecting the skin may be more common in this patient group Immunosuppressed patients are at increased risk for herpes simplex and herpes zoster Any skin lesions in a dermatomal distribution, with or without associated pain and whether or not the lesions are “classic,” should be considered herpes zoster until proven otherwise Immunocompromised patients with herpes zoster have an increased risk of disseminated disease and should be placed in respiratory isolation Evaluation should include chest radiograph and liver function tests If there is a vesicular lesion, it should be scraped and sent for both rapid testing (e.g., PCR) and culture for herpes simplex and varicella zoster Empiric therapy should be started with either acyclovir or one of its derivatives Admission for intravenous therapy is indicated in patients in whom there is evidence of dissemination, ophthalmologic involvement, or failure to respond to oral therapy Oral home therapy can be considered in consultation with the oncologist after considering extent of involvement, degree of underlying immunosuppression, likelihood of medication compliance at home, and ability to follow up COMPLICATIONS OF HEMATOPOIETIC STEM CELL TRANSPLANTATION Bone marrow transplantation is increasingly utilized in the treatment of various hematologic, oncologic, metabolic, or immunologic diseases In hematologic malignancies, allogeneic marrow transplantation may follow initial remission, induction, or disease relapse The allogeneic donor may be related, usually a sibling, or unrelated to the recipient In solid tumors and some lymphomas, patients may receive aggressive chemotherapy and radiation and then have their own stem cells infused as a “rescue” to help reconstitute their immune system following therapy (autologous transplant) Knowledge of the type of transplant a patient received ( Table 98.11 ) can help the clinician anticipate what complications might ensue In general, stem cell transplant recipients represent a fragile patient population at risk for many complications In approaching these patients, substantial immunosuppression should be presumed for at least months following the transplant For patients still receiving immunosuppressing medications, the period of immune dysfunction may be much longer Regardless of the WBC and neutrophil counts, immune function following a stem cell transplant can be profoundly impaired Graft-versus-host disease (GVHD) may develop in the setting of allogeneic stem cell transplants as newly engrafted immune cells of the donor react against tissue antigens of the recipient that are perceived to be foreign ( Table 98.11 ) Acute GVHD occurs in the first 100 days posttransplant, often when patient is still in