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Varicella

Chicken Pox

Varicella is a highly contagious, viral disease, caused by primary infection with varicella zoster virus. Manifestations include a characteristic rash, fever, malaise and headache.


Presentation

The initial prodromal phase of varicella consists of malaise and low grade fever. Fever is rarely above 102 F. The characteristic feature of varicella is the formation of cutaneous vesicles. Exanthem develops over 3 to 6 days. Usually it begins along the hairline on the face as red macules that progress to tiny vesicles with surrounding erythema. It is often described as “dew drops on a rose petal”. The vesicles then form pustules which become crusted and scabbed over. The rash appears in successive crops over the trunk and then the extremities. In the first week, there are lesions in different stages of development. By the end of the first week, the fever subsides and the cutaneous lesions start crusting, become dry and fall off. Eventually they heal leaving no scar behind.

Complications of varicella include the following:

Fever
  • Over-the-counter Medications Use non-aspirin medications, such as acetaminophen, to relieve fever from chickenpox. Do not use aspirin or aspirin-containing products to relieve fever from chickenpox.[web.archive.org]
  • Instead, use non-aspirin medications, such as acetaminophen, to relieve fever from chickenpox.[cdc.gov]
  • The most frequent solicited local adverse event after MMRV vaccine is redness, and fever is the most common solicited general symptom.[ncbi.nlm.nih.gov]
  • Manifestations include a characteristic rash, fever, malaise and headache. The initial prodromal phase of varicella consists of malaise and low grade fever. Fever is rarely above 102 F.[symptoma.com]
  • Varicella was diagnosed in a 5-year-old boy with acute lymphoblastic leukemia complaining of fever and abdominal pain followed by papulovesicular skin lesions.[ncbi.nlm.nih.gov]
Malaise
  • Manifestations include a characteristic rash, fever, malaise and headache. The initial prodromal phase of varicella consists of malaise and low grade fever. Fever is rarely above 102 F.[symptoma.com]
  • In healthy children, varicella is generally mild, with an itchy rash, malaise, and temperature up to 102 F for 2 to 3 days.[web.archive.org]
  • Prodromal symptoms consist of low-grade fever , headache , anorexia , and malaise. On the following day, the characteristic rash begins to appear. The lesions evolve from erythematous macules to form small papules .[medicinenet.com]
  • It is characterized by an itchy, vesicular rash, usually starting on the scalp and face, initially accompanied by fever and malaise. As the rash gradually spreads to the trunk and extremities, the first vesicles dry out.[who.int]
  • They include: Headache or feelings of general illness (malaise). Nausea and vomiting. Diarrhea or constipation. This is rare. Kidney problems in people who receive large doses of acyclovir by rapid injection into a vein. This is rare.[web.archive.org]
Fatigue
  • She presented clinically with sudden onset of fatigue, vertigo, nausea and epileptic seizures. Investigations of the cerebrospinal fluid revealed 522/3 cells, lactate 2.9 mmol/L, protein 232 mg/dL and 2.4 10 3 varicella zoster virus.[ncbi.nlm.nih.gov]
  • Symptoms Generalized red, itchy vesicles on the trunk and face that spread to the extremities Fever Fatigue Cough Varivax Vaccine The Varivax vaccine is used to protect against chickenpox. It is effective in 70-90% of those who receive the vaccine.[students.case.edu]
  • Definition of Chickenpox Chickenpox: A highly infectious viral disease also known medically as varicella -- in many countries, this disease is always called "varicella" -- that causes a blister-like rash, itching, fatigue and fever.[web.archive.org]
  • Chickenpox: A highly infectious viral disease also known medically as varicella -- in many countries, this disease is always called "varicella" -- that causes a blister-like rash, itching, fatigue and fever.[medterms.com]
  • Full Chicken Pox Photo Gallery Chicken Pox Treatment - Acetaminophen Patients with chicken pox typically have viral-type, prodromal symptoms such as headache, fever, fatigue, and muscle aches.[web.archive.org]
Low Fever
  • Patients typically are afebrile or have low fever and develop fewer than 50 skin lesions. They usually have a shorter illness compared to unvaccinated people who get varicella.[web.archive.org]
  • They may include: Pain, swelling, and redness where the shot was given Mild rash Low fever Serious side effects from the chickenpox vaccine are very rare.[vaccines.gov]
  • Although the lesions may appear alarming, varicella in children is usually a mild disease with few complications and a low fever. Occasionally, if the rash is severe, the fever may be higher.[encyclopedia.com]
Cough
  • The virus spreads from person to person by direct contact or through the air by coughing or sneezing. It takes from 10-21 days after contact with an infected person for someone to develop chickenpox.[web.archive.org]
  • Chickenpox spreads in the air through coughing or sneezing. It can also be spread by touching or breathing in the virus particles that come from chickenpox blisters. The best way to prevent chickenpox is to get the chickenpox vaccine.[web.archive.org]
  • The main presenting symptoms were itchy skin rash, fever, cough, sputum, breathlessness, throat pain, vomiting, abdominal pain, confusion and headache.[ncbi.nlm.nih.gov]
  • Chickenpox is a contagious air-borne disease spread through coughing or sneezing and by touching or breathing in virus particles from chickenpox blisters.[web.archive.org]
Eruptions
  • There are practically no premonitory symptoms, though slight fever for about 24 hours may precede the eruption.[britannica.com]
  • An 18-year-old male with Cushing's disease presented with generalised skin eruptions and backache. He was diagnosed with varicella infection. During the course of the illness, he developed persistent vomiting.[ncbi.nlm.nih.gov]
  • The patient developed a disseminated papulo-vesiculous eruption, diagnosed as varicella.[ncbi.nlm.nih.gov]
  • Upon examination, the child was found to have a zosteriform radicular pattern of skin eruption corresponding to dermatomes C6, C7, and C8. The eruption was patchy, flat, nonblistering, and eczematous.[bcmj.org]
  • The incubation period is from 10 to 21 days (most commonly 14 to 16) The illness has a short prodrome of fever, lethargy and anorexia followed by eruption of the rash that occurs over the next three to five days.[rch.org.au]
Eczema
  • Antiviral medicine may be very important for those who have skin conditions (such as eczema or recent sunburn), lung conditions (such as asthma), or who have recently taken steroids.[nlm.nih.gov]
  • Oral acyclovir is more strongly recommended for children with underlying skin disease such as eczema, newborns, adults, and smokers since this group is at greater risk for complications.[web.archive.org]
  • Allergic rhinitis, asthma, and atopic eczema are among the commonest causes of chronic ill health. These diseases are increasing in prevalence, and they add considerably to the burden of health care costs.[doi.org]
Vesicular Rash
  • Abstract The earliest reports of vesicular rashes of the type we now recognize to be caused by herpes simplex and zoster date to the ancient civilizations.[ncbi.nlm.nih.gov]
  • Abstract A 79-year-old man with chronic lymphocytic leukaemia presented with fever and a widespread vesicular rash on 19 November 2014. The patient had not been under immunosuppressive regime for 6 months.[ncbi.nlm.nih.gov]
  • Abstract A 64-year-old immunocompetent man developed a widespread pruritic and vesicular rash 2 weeks after receiving the zoster vaccine (Zostavax). He had fever, bandaemia with normal total white blood cell count and mild transaminitis.[ncbi.nlm.nih.gov]
  • The diagnosis of varicella is usually made on clinical grounds on the basis of the characteristic vesicular rash. The following investigations may be helpful in establishing the diagnosis if clinical examination is not sufficient.[symptoma.com]
Pruritus
  • Her mother reports that she is scratching continuously and has had very little sleep over the past few days as a result of the pruritus.[web.archive.org]
  • Figures and Tables - Analysis 2.10 Comparison 2 Zoster vaccine versus placebo subgroup analysis by age, Outcome 10 Pruritus inoculation site.[dx.doi.org]
  • There is a possible association with non-steroidal anti-inflammatory drugs (NSAIDs) and risk of necrotising soft tissue infections. [ 6 ] Pruritus can be helped by sedating antihistamines and emollients.[patient.info]
Purpura
  • Five major clinical syndromes have been described: febrile purpura, malignant chickenpox with purpura, postinfectious purpura, purpura fulminans, and anaphylactoid purpura.[en.wikipedia.org]
  • Purpura fulminans: Purpura fulminans is a large ecchymosis that appears on the legs. Occasionally, it may progress to hemorrhagic gangrene.[symptoma.com]
  • […] guidance on varicella vaccination in the European Union Peer-Reviewed Publication Varicella vaccination: A laboured take-off News Long-term Effectiveness of Varicella Vaccine: A 14-Year, Prospective Cohort Study News The risk of immune thrombocytopenic purpura[ecdc.europa.eu]
  • Hemic and Lymphatic System: Aplastic anemia; thrombocytopenia (including idiopathic thrombocytopenic purpura (ITP)). Infections and Infestations: Varicella (vaccine strain).[drgreenmom.com]
  • Henoch-Schönlein purpura (a condition that can affect the kidneys). Inflammation of the testes (orchitis). Inflammation of the joints (arthritis). Inflammation of various parts of the eye.[patient.info]
Headache
  • We report an unusual case of an immunocompetent young adult presenting with occipital headache and zoster rash, without preherpetic and postherpetic neuralgia, who was diagnosed with varicella meningitis on Polymerase chain reaction (PCR).[ncbi.nlm.nih.gov]
  • Other typical symptoms that may begin to appear 1-2 days before rash include: high fever tiredness loss of appetite headache Children usually miss 5 to 6 days of school or childcare due to their chickenpox.[web.archive.org]
  • Other typical symptoms that may begin to appear 1-2 days before rash include: fever tiredness loss of appetite headache Children usually miss 5 to 6 days of school or childcare due to chickenpox.[cdc.gov]
  • Symptoms can include a headache, sensitivity to light, neck stiffness and pain, delirium, and seizures.[dermatology.about.com]
  • The main presenting symptoms were itchy skin rash, fever, cough, sputum, breathlessness, throat pain, vomiting, abdominal pain, confusion and headache.[ncbi.nlm.nih.gov]
Febrile Convulsions
  • Higher rates of fever and febrile convulsions compared to MMR /-V have been reported when used as first dose but not when used as the second of a measles containing vaccine, irrespective of age of the second dose.[ncbi.nlm.nih.gov]

Workup

The diagnosis of varicella is usually made on clinical grounds on the basis of the characteristic vesicular rash. The following investigations may be helpful in establishing the diagnosis if clinical examination is not sufficient.

  • Blood count: White blood cells are usually normal or low. Increase in the number of white blood cells suggests secondary bacterial infection
  • Chest X-ray: In case of varicella pneumonitis, numerous bilateral nodular opacities may be seen in X-rays of the chest. Hyperinflation may also be apparent.
  • Viral sampling and cell culture: Varicella zoster virus may be identified by obtaining samples of the fluid in the vesicles and for inoculation in cell culture.
  • Immunological tests: The most reliable methods for testing varicella zoster humoral immunity are fluorescent antibody to membrane antigen (FAMA) and enzyme linked immunosorbent assay (ELISA) [3]. 
Human Herpesvirus 3
  • None have yet been reported in varicella-zoster virus (VZV; also known as human herpesvirus 3 [HHV-3]).[ncbi.nlm.nih.gov]
  • Varicella, the primary infection with varicella-zoster virus (VZV; human herpesvirus 3), in pregnancy may cause maternal mortality or serious morbidity.[rcog.org.uk]
  • Human herpesvirus 3 Human herpesvirus 3 [X04370 NC_001348] (HHV-3) (Varicella-zoster virus) "Pathogen Safety Data Sheets: Infectious Substances – Varicella-zoster virus". canada.ca.[en.wikipedia.org]

Treatment

In a healthy child, varicella is not a serious disease. The treatment of varicella consists of the following components.

  • Maintenance of hydration: It is important to maintain hydration in the children suffering from varicella.
  • Good hygiene: General good hygiene should be maintained by keeping the nails trimmed and keeping the skin clean. This reduces itching and the likelihood of damaging the skin due to sharp nails.
  • Antipyretics: Paracetamol is the antipyretic used to control the low grade fever of paracetamol. Aspirin should be avoided to avoid the risk of Reye’s syndrome.
  • Calamine lotion: Calamine lotion may be applied on the skin to relieve the severe itching associated with varicella. 
  • Diphenhydramine syrup: In case of uncontrolled itching and discomfort, diphenhydramine syrup may be given to provide adequate relief.
  • Antibiotics: In case of secondary infection of the skin, antibiotic therapy is necessitated. 
  • Varicella zoster immunoglobulin (VZIG): Varicella zoster immunoglobulin (VSIG) may be given in the children who are immunocompromised or who are receiving corticosteroid therapy for any other condition [4] [5].
  • Acyclovir: In case of varicella infection, there is no beneficial effect of varicella zoster immunoglobulin after 4th day post-exposure. In such cases, acyclovir is given for 7 days in a total daily dose of 1500 mg per square meter of surface area. Intravenous acyclovir blocks further viral replication within 24 to 48 hours. Such early treatment prevents the development of progressive varicella and its associated complications [6] [7].

Prognosis

Varicella is not a very serious disease and therefore, the prognosis is usually good. The mortality depends upon the health and the age of the child. The mortality rate of children suffering from varicella is around 1 in 50,000 children. In infants, the mortality is much higher at 1 in 13,000 children. Children on high dose steroid therapy have a greater risk of developing complications of varicella. Mortality from varicella has declined in the United States since the implementation of vaccination [2].

Etiology

Varicella is caused by one of the human herpes viruses; specifically varicella zoster virus (VZV). Varicella zoster virus is a DNA virus and is transmitted by droplets in respiratory secretions. Air currents from an infected child to a susceptible child carry these water droplets. Varicella is contagious from 24 to 48 hours before the rash appears and while uncrusted vesicles are present – which is around 3 to 7 days.

Epidemiology

Varicella is a common disease of children. It occurs equally in all races and genders [1].

Sex distribution
Age distribution

Pathophysiology

After a susceptible child receives the virus, there is an incubation period of around 10 to 20 days before the appearance of the characteristic vesicular rash. The initial site of infection is the conjunctivae or the upper respiratory tract. The virus then replicates for about 4 to 6 days at a local site in the head or neck. Thereafter, the virus is transmitted throughout the body which is known as primary viremia. One week later, the virus is released in large amounts after a second replication. This is known as secondary viremia. The virus then leaves the capillaries and invades the epidermis of the skin. The characteristic vesicles of varicella then appear on the skin.

Prevention

Varicella can be prevented by the use of varicella vaccine [8]. Varicella vaccine is not recommended below the age of 1 year. After the age of one year, a single dose of 0.5 ml is recommended. Herpes zoster may also be prevented in adults by the use of varicella vaccine [9] [10]. Infection with varicella confers lifelong immunity in the host.

Summary

Varicella, more commonly known as chicken pox, is a common exanthem of the pediatric population. It is caused by varicella zoster virus. The salient features of varicella are malaise, rash, fever and headache. After recovery from the initial infection, the virus still remains in a latent state within the dorsal root (sensory) ganglion cells. In around 10 to 15% of the cases, the virus may reactivate in old age when the immune system becomes weak. In such cases, there is a characteristic exanthem in a dermatomel pattern which is referred to as herpes zoster or shingles.

Patient Information

Varicella is a common infectious disease of children and is known as chicken pox. It is caused by a virus and is characterized by the formation of rash. It is not a serious disease but prompt treatment is necessary to prevent the development of complications.

References

Article

  1. Choo PW, Donahue JG, Manson JE, Platt R. The epidemiology of varicella and its complications. The Journal of infectious diseases. Sep 1995;172(3):706-712.
  2. Nguyen HQ, Jumaan AO, Seward JF. Decline in mortality due to varicella after implementation of varicella vaccination in the United States. The New England journal of medicine. Feb 3 2005;352(5):450-458.
  3. Sauerbrei A, Wutzler P. Serological detection of specific IgG to varicella-zoster virus by novel ELISA based on viral glycoprotein antigen. Clinical laboratory. 2009;55(1-2):1-7.
  4. Kim JH, Kwon DH, Bae EY, et al. Use of intravenous immunoglobulin in a disseminated varicella infection in an immunocompromised child. Korean journal of pediatrics. Aug 2014;57(8):370-373.
  5. Lu YC, Fan HC, Wang CC, Cheng SN. Concomitant use of acyclovir and intravenous immunoglobulin rescues an immunocompromised child with disseminated varicella caused multiple organ failure. Journal of pediatric hematology/oncology. Dec 2011;33(8):e350-351.
  6. Rosenberg NM, Brenner SL, Singer JI, Woodward GA. Use of acyclovir in varicella. Pediatric emergency care. Feb 1993;9(1):57-59.
  7. Vilde JL, Longuet P. [Acyclovir and infections caused by varicella-zoster viruses]. La Revue du praticien. Oct 15 1994;44(16):2133-2136.
  8. Dennehy PH. Varicella vaccine for prevention of chickenpox. Rhode Island medicine. Jan 1995;78(1):14-16.
  9. Hambleton S. Prevention of varicella and zoster by live attenuated VZV vaccine. Frontiers in bioscience : a journal and virtual library. 2008;13:2696-2704.
  10. Caple J. Varicella-zoster virus vaccine: a review of its use in the prevention of herpes zoster in older adults. Drugs of today. Apr 2006;42(4):249-254.

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Last updated: 2019-07-11 22:38