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Section 3. Summaries of Infectious Diseases Varicella-Zoster Infections Clinical Manifestations Etiology Epidemiology Diagnostic Tests Treatment Isolation of the Hospitalized Patient Control Measures Care of Exposed People
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CLINICAL MANIFESTATIONS Primary infection results in varicella (chickenpox), manifesting as a generalized, pruritic, vesicular rash typically consisting of 250 to 500 lesions in varying stages of development and resolution (crusting), mild fever, and other systemic symptoms. Complications include bacterial superinfection of skin lesions, pneumonia, central nervous system involvement (acute cerebellar ataxia, encephalitis), thrombocytopenia, and other rare complications, such as glomerulonephritis, arthritis, and hepatitis. Varicella tends to be more severe in adolescents and adults than in young children. Breakthrough chickenpox cases usually are mild and can occur in immunized children, as described later in Active Immunization (p 721). Reye syndrome can follow cases of chickenpox, although today Reye syndrome is very rare because of decreased use of salicylates during varicella. In immunocompromised children, progressive, severe varicella

characterized by continuing eruption of lesions and high fever persisting into the second week of illness as well as encephalitis, hepatitis, and pneumonia can develop. Hemorrhagic varicella is much more common among immunocompromised patients than among immunocompetent hosts. Pneumonia is relatively less common among immunocompetent children but is the most common complication in adults. In children with human immunodeficiency virus (HIV) infection, recurrent varicella or disseminated herpes zoster can develop. Severe and even fatal varicella has been reported in otherwise healthy children receiving intermittent courses of high-dose corticosteroids (greater than 2 mg/kg of prednisone or equivalent) for treatment of asthma and other illnesses. The risk especially is high when corticosteroids are given during the incubation period for chickenpox. Varicella-zoster virus (VZV) establishes latency in the dorsal root ganglia during primary infection. Reactivation results in herpes zoster ("shingles"), characterized by grouped vesicular lesions in the distribution of 1 to 3 sensory dermatomes, sometimes accompanied by pain localized to the area. Postherpetic neuralgia, which may last for weeks to months, is defined as pain that persists after resolution of the zoster rash. Zoster occasionally can become disseminated in immunocompromised patients, with lesions appearing outside the primary dermatomes and with visceral complications. Fetal infection after maternal varicella during the first or early second trimester of pregnancy occasionally results in fetal death or varicella embryopathy, characterized by limb hypoplasia, cutaneous scarring, eye abnormalities, and damage to the central nervous system (the congenital varicella syndrome). The incidence of congenital varicella syndrome among infants born to mothers with varicella is approximately 1% to 2% when infection occurs before 20 weeks of gestation. Children exposed to VZV in utero during the second 20 weeks of pregnancy can develop inapparent varicella and subsequent zoster early in life without having had extrauterine varicella. Two cases of congenital varicella syndrome have been reported after 20 weeks of pregnancy, the latest occurring at 28 weeks. Varicella infection can be fatal for an infant if the mother develops varicella from 5 days before to 2 days after delivery. When varicella develops in a mother more than 5 days before delivery and gestational age is 28 weeks or more, the severity of disease in the newborn infant is modified by transplacental transfer of VZV-specific maternal immunoglobulin (Ig) G antibody.
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ETIOLOGY VZV is a member of the herpesvirus family.

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EPIDEMIOLOGY Humans are the only source of infection for this highly contagious virus. Humans are infected when the virus comes in contact with the mucosa of the upper respiratory tract or the conjunctiva. Person-to-person transmission occurs from patients with varicella by direct contact, airborne droplets, or infected respiratory tract secretions, and from contact with vesicular zoster lesions. In utero infection also can occur as a result of transplacental passage of virus during maternal varicella infection. VZV infection in a household member usually results in infection of almost all susceptible people in that household. Children who acquire their infection at home (secondary family cases) often have more skin lesions than the index case. Health care-associated transmission is well documented in pediatric units, but transmission is rare in newborn nurseries. In temperate climates in the prevaccine era, varicella was a childhood disease with a marked seasonal distribution with peak incidence during late winter and early spring. In tropical climates, the epidemiology of varicella is different; acquisition of disease occurs at later ages, resulting in a higher proportion of adults being susceptible to varicella compared with adults in temperate climates. In the prevaccine era, most cases of varicella in the United States occurred in children younger than 10 years of age. Following implementation of universal immunization in 1995, varicella disease has declined in all age groups with evidence of herd protection. The age of peak varicella incidence is shifting from children younger than 10 years of age to children 10 through 14 years of age, although the incidence in this and all age groups is lower than in the prevaccine era. Immunity generally is lifelong. Cellular immunity is more important than humoral immunity for limiting the extent of primary infection with VZV and for preventing reactivation of virus with herpes zoster. Symptomatic reinfection is uncommon in immunocompetent people; asymptomatic reinfection is more frequent. Asymptomatic primary infection is unusual, but because some cases are mild, they may not be recognized. In 2007, 90% of 19- through 35-month-old children in the United States had received 1 dose of varicella vaccine. As vaccine coverage increases and the incidence of wild-type varicella decreases, a greater number of varicella cases are occurring in immunized people as breakthrough disease. This should not be confused as an increasing rate of breakthrough disease or as evidence of increasing vaccine failure. In the surveillance areas with high vaccine coverage, the rate of varicella disease decreased by approximately 85% from 1995 to 2004 with use of varicella vaccine. Immunocompromised people with primary (varicella) or recurrent (zoster) infection are at increased risk of severe disease. Severe varicella and disseminated zoster are more likely to develop in children with congenital T-lymphocyte defects or acquired immunodeficiency

syndrome than in people with B-lymphocyte abnormalities. Other groups of pediatric patients who may experience more severe or complicated disease include infants, adolescents, patients with chronic cutaneous or pulmonary disorders, and patients receiving systemic corticosteroids or long-term salicylate therapy. Patients are contagious from 1 to 2 days before the rash to crusting of all lesions. The incubation period usually is 14 to 16 days and occasionally is as short as 10 or as long as 21 days after contact. The incubation period may be prolonged for as long as 28 days after receipt of Varicella-Zoster Immune Globulin (VariZIG) or Immune Globulin Intravenous (IGIV) and shortened in immunocompromised patients. Varicella can develop between 1 and 16 days of life in infants born to mothers with active varicella around the time of delivery; the usual interval from onset of rash in a mother to onset in her neonate is 9 to 15 days.

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DIAGNOSTIC TESTS Diagnostic tests for VZV are summarized in Table 3.89, p 717. Vesicular fluid or a scab can be used to identify VZV using a polymerase chain reaction (PCR) test. VZV also can be isolated from scrapings of a vesicle base during the first 3 to 4 days of the eruption, sometimes from saliva or buccal swabs, but rarely from other sites (except with severe, disseminated disease), including respiratory tract secretions. Isolation of virus or rapid diagnostic tests (PCR, direct fluorescent antibody) are the methods of choice. Viral culture is less sensitive than PCR testing. Strain identification (genotyping) can distinguish wild-type VZV from the vaccine strain; however, testing is only available at highly specialized reference laboratories (eg, the Centers for Disease Control and Prevention [CDC]). A significant increase in serum varicella IgG antibody from acute and convalescent samples by any standard serologic assay can confirm a diagnosis retrospectively. These antibody tests are fairly reliable for diagnosing natural infection in healthy hosts but may not be reliable in immunocompromised people (see Care of Exposed People, p 718). Commercially available tests are not sufficiently sensitive to demonstrate reliably a vaccine-induced antibody response. IgM tests are not reliable for routine confirmation or ruling out of acute infection, but positive results suggest current or recent VZV infection or reactivation.

View this table: [in this window] Table 3.89. Diagnostic Tests for Varicella-Zoster Virus (VZV) Infection [in a new window]

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TREATMENT The decision to use antiviral therapy and the route and duration of therapy should be determined by specific host factors, extent of infection, and initial response to therapy. Antiviral drugs have a limited window of opportunity to affect the outcome of VZV infection. In immunocompetent hosts, most virus replication has stopped by 72 hours after onset of rash; the duration of replication may be extended in immunocompromised hosts. Oral acyclovir is not recommended for routine use in otherwise healthy children with varicella. Administration within 24 hours of onset of rash results in only a modest decrease in symptoms. Oral acyclovir should be considered for otherwise healthy people at increased risk of moderate to severe varicella, such as people older than 12 years of age, people with chronic cutaneous or pulmonary disorders, people receiving long-term salicylate therapy, and people receiving short, intermittent, or aerosolized courses of corticosteroids. Some experts also recommend use of oral acyclovir for secondary household cases in which the disease usually is more severe than in the primary case. For recommendations on dosage and duration of therapy, see Antiviral Drugs (p 777). Acyclovir is a category B drug based on US Food and Drug Administration (FDA) Drug Risk Classification in pregnancy. Some experts recommend oral acyclovir for pregnant women with varicella, especially during the second and third trimesters. Intravenous acyclovir is recommended for the pregnant patient with serious complications of varicella. VariZIG or IGIV can be used during pregnancy for susceptible women who are exposed to VZV. Intravenous antiviral therapy is recommended for immunocompromised patients, including patients being treated with chronic corticosteroids. Therapy initiated early in the course of the illness, especially within 24 hours of rash onset, maximizes efficacy. Oral acyclovir should not be used to treat immunocompromised children with varicella because of poor oral bioavailability. Some experts have used high-dose oral acyclovir, valacyclovir, or famciclovir in selected immunocompromised patients perceived to be at lower risk of developing severe varicella, such as HIV-infected patients with relatively normal concentrations of CD4+ T-lymphocytes and children with leukemia in whom careful follow-up is ensured. Although VariZIG or, if not available, IGIV given shortly after exposure can prevent or modify the course of disease, Immune Globulin preparations are not effective once disease is established (see Care of Exposed People, p 718). Famciclovir and valacyclovir have been licensed for treatment of zoster in adults. Famciclovir is converted to penciclovir, which has an extended half-life in infected cells. Valacyclovir is converted to acyclovir and produces fourfold greater serum concentrations than those produced by oral acyclovir. No pediatric formulation is available for either medication, and insufficient data exist on the use or dose of these drugs in children to support therapeutic recommendations.

Infections caused by acyclovir-resistant VZV strains, which generally are limited to immunocompromised hosts, should be treated with parenteral foscarnet. Children with varicella should not receive salicylates or salicylate-containing products, because administration of salicylates to such children increases the risk of Reye syndrome. Salicylate therapy should be stopped in a child who is exposed to varicella.

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ISOLATION OF THE HOSPITALIZED PATIENT In addition to standard precautions, airborne and contact precautions are recommended for patients with varicella for a minimum of 5 days after onset of rash and until all lesions are crusted, which in immunocompromised patients can be a week or longer. For immunized patients with breakthrough varicella with only maculopapular lesions, isolation is recommended until no new lesions occur or the lesions have faded; lesions do not have to be completely resolved. For exposed patients without evidence of immunity (see Evidence of Immunity to Varicella, p 724), airborne and contact precautions from 8 until 21 days after exposure to the index patient also are indicated; these precautions should be maintained until 28 days after exposure for those who received VariZIG or IGIV. Airborne and contact precautions are recommended for neonates born to mothers with varicella and, if still hospitalized, should be continued until 21 or 28 days of age if they received VariZIG or IGIV. Infants with varicella embryopathy do not require isolation if they do not have active lesions. Immunocompromised patients who have zoster (localized or disseminated) and immunocompetent patients with disseminated zoster require airborne and contact precautions for the duration of illness. For immunocompetent patients with localized zoster, contact precautions are indicated until all lesions are crusted.

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CONTROL MEASURES

Child Care and School Children with uncomplicated chickenpox who have been excluded from school or child care may return when the rash has crusted, or in immunized people without crusts, until lesions are resolving. Exclusion of children with zoster whose lesions cannot be covered is based on similar criteria. Children who are excluded may return after the lesions have crusted. Lesions that are covered pose little risk to susceptible people. Older children and staff members with zoster should be instructed to wash their hands if they touch potentially infectious lesions.

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CARE OF EXPOSED PEOPLE Potential interventions for people without evidence of immunity exposed to a person with varicella include either varicella vaccine administered ideally within 3 days but up to 5 days after exposure or, when indicated, VariZIG (1 dose up to 96 hours after exposure). If VariZIG is not available, IGIV (1 dose up to 96 hours after exposure) can be used (see Unavailability of VariZIG, p 721). 229 Prophylactic administration of oral acyclovir beginning 7 days after exposure also may prevent or attenuate varicella disease. Hospital Exposure If an inadvertent exposure in the hospital to an infected patient, health care professional, or visitor occurs, the following control measures are recommended:

Health care professionals and patients who have been exposed (see Table 3.90, p 720) and who lack evidence of immunity to varicella should be identified. Varicella immunization is recommended for people without evidence of immunity, provided there are no contraindications to vaccine use. VariZIG should be administered to appropriate candidates (see Table 3.91, p 721). If VariZIG is not available, IGIV is recommended. All exposed patients without evidence of immunity should be discharged as soon as possible. All exposed susceptible patients who cannot be discharged should be placed in isolation from day 8 to day 21 after exposure to the index patient. For people who received VariZIG or IGIV, isolation should continue until day 28. All exposed health care professionals without evidence of immunity should be furloughed or excused from patient contact from day 8 to day 21 after exposure to an infectious patient or to day 28 for people who have received VariZIG or IGIV.

Serologic testing for immunity is not necessary for health care professionals who have been immunized, because most adults are immune after the second vaccine dose and because most serologic assays will not reliably detect immunity resulting from vaccines. For more information, see the recommendations of the Advisory Committee on Immunization Practices (ACIP) of the CDC. 230 Immunized health care professionals who develop breakthrough infection should be considered infectious.

View this table: [in this window] [in a new window]

Table 3.90. Types of Exposure to Varicella or Zoster for Which VariZIG Is Indicated for People Without Evidence of Immunitya

View this table: [in this window] Table 3.91. Candidates for VariZIG or Acyclovir, Provided Significant [in a new Exposure Has Occurreda window] Postexposure Immunization Administration of varicella vaccine to people without evidence of immunity 12 months of age or older, including adults, as soon as possible within 72 hours and possibly up to 120 hours after varicella exposure may prevent or modify disease and should be considered in these circumstances if there are no contraindications to vaccine use. Physicians should advise parents and their children that the vaccine may not protect against disease in all cases, because some children may have been exposed at the same time as the index case. However, if exposure to varicella does not cause infection, postexposure immunization with varicella vaccine will result in protection against subsequent exposure. There is no evidence that administration of varicella vaccine during the presymptomatic or prodromal stage of illness increases the risk of vaccine-associated adverse events or more severe natural disease. Passive Immunoprophylaxis The decision to administer VariZIG depends on 3 factors: 1. the likelihood that the exposed person has no evidence of immunity to varicella; 2. the probability that a given exposure to varicella or zoster will result in infection; and 3. the likelihood that complications of varicella will develop if the person is infected. Data are unavailable regarding the sensitivity and specificity of serologic tests in immunocompromised patients. However, no test is 100% sensitive or specific and, consequently, false-positive results can occur. Therefore, regardless of serologic test results, careful questioning

of childrens parents about potential past exposure to disease or clinical description of disease can be helpful in determining immunity. Administration of VariZIG or IGIV as soon as possible within 96 hours to exposed immunocompromised children with no history of varicella and unknown or negative serologic test results usually is advised. The degree and type of immunosuppression should be considered in making this decision. VariZIG is given intramuscularly at the recommended dose of 125 units/10 kg body weight, up to a maximum of 625 units (ie, 5 vials). IGIV is given intravenously at the dose of 400 mg/kg. Patients receiving monthly high-dose IGIV (400 mg/kg or greater) at regular intervals are likely to be protected if the last dose of IGIV was given 3 weeks or less before exposure. Where to Obtain VariZIG VariZIG is available under an investigational new drug (IND) protocol and can be requested by calling the 24-hour telephone number of FFF Enterprises (800-8437477). Indications for VariZIG Tables 3.90 (above) and 3.91 (p 721) indicate people without evidence of immunity who should receive VariZIG if exposed, including immunocompromised people, pregnant women, and certain newborn infants. For healthy term infants exposed postnatally to varicella, including infants whose mothers rash developed more than 48 hours after delivery, VariZIG is not indicated. However, some experts advise use of VariZIG for any exposed newborn who has severe skin disease and whose mother does not have evidence of immunity.

Subsequent exposures and follow-up of VariZIG recipients . Because administration of VariZIG can cause varicella infection to be asymptomatic, testing of recipients 2 months or later after administration of VariZIG to ascertain their immune status may be helpful in the event of subsequent exposure. Some experts, however, would advise VariZIG administration after subsequent exposures regardless of serologic results because of the unreliability of serologic test results in immunocompromised people and the uncertainty about whether asymptomatic infection after VariZIG administration confers lasting protection.

Any patient to whom VariZIG is administered to prevent varicella subsequently should receive age-appropriate varicella vaccine, provided the vaccine is not contraindicated. Varicella immunization should be delayed until 5 months after VariZIG administration. Varicella vaccine is not needed if the patient develops varicella after administration of VariZIG. Unavailability of VariZIG If VariZIG is not available, IGIV can be used. The recommendation for use of IGIV is based on "best judgment of experts" and is supported by reports comparing VZV IgG antibody titers measured in both IGIV and VariZIG preparations and patients given IGIV and VariZIG. Although licensed IGIV preparations contain antivaricella antibodies, the titer of any specific lot of IGIV is uncertain, because IGIV is not tested routinely for antivaricella antibodies. No clinical data demonstrating effectiveness of IGIV for postexposure prophylaxis of varicella are available. The recommended IGIV dose for postexposure prophylaxis of varicella is 400 mg/kg, intravenously administered once.

Chemoprophylaxis If VariZIG is not available or more than 96 hours have passed since exposure, some experts recommend prophylaxis with acyclovir (80 mg/kg per day, administered 4 times/day for 7 days; maximum dose, 800 mg, 4 times/day) beginning 7 to 10 days after exposure for immunocompromised patients without evidence of immunity who have been exposed to varicella. A 7-day course of acyclovir also may be given to adults without evidence of immunity if vaccine is contraindicated. Limited data on acyclovir as postexposure prophylaxis are available for healthy children; no studies were performed for adults. However, limited data support use of acyclovir as postexposure prophylaxis, and clinicians may choose this option if active or passive immunization is not possible. Most adults with no history or an uncertain history of chickenpox are immune if they were raised in the continental United States or Canada. Active Immunization 231, 232 Vaccine Varicella vaccine is a live-attenuated preparation of the serially propagated and attenuated wild Oka strain. The product contains trace amounts of neomycin and gelatin. The monovalent vaccine was licensed in March 1995 by the FDA for use in healthy people 12 months of age or older who have not had varicella illness. Quadrivalent measles-mumps-rubella-varicella (MMRV) vaccine was licensed in September 2005 by the FDA for use in healthy children 12 months through 12 years of age. Dose and Administration The recommended dose of the vaccine is 0.5 mL administered subcutaneously. Immunogenicity Approximately 85% of immunized healthy children older than 12 months of age develop humoral and cell-mediated immune response to VZV at levels associated with protection after a single dose of varicella vaccine. Seroprotection rates are significantly higher (approaching 100%) after 2 doses. Effectiveness The efficacy of 1 dose of varicella vaccine ranges from 70% to 90% against infection and 95% against severe disease. In general, postlicensure effectiveness studies have reported a similar range for prevention against infection, with a few studies yielding lower or higher values. The vaccine is highly effective (97% or greater) in preventing severe varicella in postlicensure evaluations. Recipients of 2 doses of varicella vaccine are 3.3-fold less likely to have breakthrough varicella as compared with recipients of 1 dose (2.2% vs 7.3% [P <0.001]) during the first 10 years after immunization. Breakthrough cases developed in 0.0% to 0.8% in recipients of 2 doses of vaccine per year, compared with 0.2% to 2.3% of recipients of 1 dose of vaccine. Varicella in vaccine recipients is milder than that occurring in unimmunized children, usually with a median of fewer than 50 vesicles, lower rate of fever (10% with temperature 39C [102F] or higher), and faster recovery. At times, the disease is so mild that it is not easily recognizable as varicella, because skin lesions may resemble insect bites. In contrast, the median number of lesions in unimmunized children with varicella is more than 250. However, varicella transmission from vaccine recipients with mild breakthrough disease may occur; in household settings, the risk of transmission is approximately one third that of unimmunized cases.

Duration of Immunity Although there has been concern about waning immunity, follow-up evaluations of children immunized during prelicensure clinical trials in the United States indicate persistence of antibodies for at least 8 years. Studies in Japan indicate persistence of antibodies for at least 20 years; however, these studies were conducted during a period when a substantial amount of wild-type VZV was present in the community, with many opportunities for boosting of immunity by subclinical infection. Available data are inconclusive regarding waning of immunity after one dose of varicella vaccine. For measles prevention, the primary reason for the second dose of measles vaccine is to induce protection in children without an adequate response to the first dose, not because of waning immunity. Similarly, a 2-dose schedule for varicella vaccine for all children was recommended by the American Academy of Pediatrics and CDC in 20062007. Postlicensure surveillance studies are being performed to determine the persistence of antibodies and the effectiveness of the 2-dose varicella vaccine strategy. Simultaneous Administration With Other Vaccines or Antiviral Agents Varicella-containing vaccines may be given simultaneously with other recommended childhood immunizations recommended for children 12 through 15 months of age and 4 through 6 years of age (see Fig 1.1, p 2425). If not administered at the same visit or as MMRV vaccine, the interval between administration of a varicella-containing vaccine and measles-mumps-rubella (MMR) vaccine should be at least 28 days. Because of susceptibility of vaccine virus to acyclovir, valacyclovir, or famciclovir, these antiviral agents should be avoided from 1 day before to 21 days after receipt of a varicella-containing vaccine. Adverse Events Varicella vaccine is safe; reactions generally are mild and occur with an overall frequency of approximately 5% to 35%. Approximately 20% of immunized people will experience minor injection site reactions (eg, pain, redness, swelling). In approximately 3% to 5% of immunized children, a localized rash develops, and in an additional 3% to 5%, a generalized varicella-like rash develops. However, all observed postimmunization rashes cannot be attributed to vaccine. These rashes typically consist of 2 to 5 lesions and may be maculopapular rather than vesicular; lesions usually appear 5 to 26 days after immunization. Many generalized varicelliform rashes that occur within the first 2 weeks after varicella immunization are attributable to wild-type VZV infection and are not an adverse effect of the vaccine. In a 2-dose regimen of monovalent vaccine separated by 3 months, injection site complaints were slightly higher after the second dose. After 1 dose, recipients of MMRV are more likely than are recipients of monovalent varicella vaccine and MMR given at separate injection sites to have fever (21.5% vs 14.9%, respectively) and a measles-like rash (3% vs 2.1%, respectively). Both fever and measles-like rash usually occurred within 5 to 12 days of immunization, were of short duration, and resolved without long-term sequelae. A 2.3 times higher relative risk for confirmed febrile seizures was found in children 12 through 23 months of age during the period of 5 through 12 days after MMRV immunization when compared with same-aged children immunized with MMR vaccine and varicella vaccine given separately at the same visit. 233 After the second dose, there were no differences in incidence of fever or rash among recipients of MMRV compared with recipients of simultaneous MMR and varicella vaccines. Serious adverse events, such as anaphylaxis, encephalitis, ataxia, erythema multiforme, Stevens-Johnson syndrome, pneumonia, thrombocytopenia, seizures, neuropathy, Guillain-Barr syndrome, secondary bacterial infections, and death have been reported rarely in temporal association with varicella vaccine. In rare instances, a causal relationship between the varicella

vaccine and some of these serious adverse events has been established, most often in children with immunocompromising conditions, although the frequency of serious adverse events is much lower than after natural infection. In most cases, data are insufficient to determine a causal association. Herpes Zoster After Immunization Varicella vaccine virus has been associated with development of herpes zoster in immunocompetent and immunocompromised people. However, data from postlicensure surveillance indicate that the clinical severity seems to be milder and the agespecific risk of herpes zoster seems to be lower among immunocompetent children immunized with varicella vaccine than among children who have had natural varicella infection. Wild-type VZV has been identified in vesicles in people with herpes zoster after immunization, indicating that herpes zoster in immunized people also may result from natural varicella infection that occurred before or after immunization. Therefore, it is important that physicians obtain eventappropriate clinical specimens for strain identification when a vaccine adverse event (eg, herpes zoster, meningitis, encephalitis) is suspected. A zoster vaccine for older adults has been licensed by the FDA in the United States and is recommended by the CDC for healthy people 60 years of age and older for the prevention of herpes zoster. 234 Among zoster vaccinees who develop zoster, postherpetic neuralgia is reduced by two thirds in vaccine recipients, compared with placebo recipients. Transmission of Vaccine-Associated Virus Vaccine-associated virus transmission to contacts is rare (only 5 instances, resulting in 6 secondary cases), and the risk of transmission exists only if a rash develops on the immunized person. Postexposure prophylaxis with VariZIG, IGIV, acyclovir, or varicella vaccine in high-risk people exposed to immunized people with lesions has not been studied. However, some experts believe that immunocompromised people in whom skin lesions develop, possibly related to vaccine virus, should receive acyclovir treatment. Attempts to identify VZV by laboratory means should be made in these patients. Storage The lyophilized vaccine should be stored in a frost-free freezer at an average temperature of 15C (+5F) or colder. The diluent used for reconstitution should be stored separately in a refrigerator or at room temperature. Once the vaccine has been reconstituted, it should be injected as soon as possible and discarded if not used within 30 minutes. Evidence of Immunity to Varicella Evidence of immunity to VZV in the pediatric population includes any of the following: 1. Documentation of 2 appropriately timed doses of varicella vaccine. 2. Laboratory evidence of immunity or laboratory confirmation of disease. 3. Varicella diagnosed by a health care professional or verification of history of varicella disease.
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For people reporting or presenting with typical disease, verification can be performed by any health care professional (eg, school or occupational clinic nurse, nurse practitioner, physician assistant, physician)

For people reporting or presenting with atypical and/or mild cases, assessment by a physician or physicians designee is recommended, and one of the following should be sought: (i) an epidemiologic link to a typical varicella case or to a laboratory-confirmed case; or (ii) evidence of laboratory confirmation, if it was performed at the time of acute disease. When such documentation is lacking, people should not be considered as having a valid history of disease, because other diseases may mimic mild atypical varicella.

4. History of herpes zoster diagnosed by a health care professional. Recommendations for Immunization Children 12 Months Through 12 Years of Age Both monovalent varicella vaccine and MMRV have been licensed for use for healthy children 12 months through 12 years of age. Children in this age group should receive two 0.5-mL doses of varicella vaccine administered subcutaneously, separated by at least 3 months. The recommendation for at least a 3-month interval between doses is based on the design of the studies evaluating 2 doses in this age group; if the second dose inadvertently is administered between 28 days and 3 months after the first dose, the second dose does not need to be repeated. All children routinely should receive the first dose of varicella-containing vaccine at 12 through 15 months of age. Because of the potential for increased febrile seizures after the first dose of MMRV vaccine in children 12 through 15 months of age, the American Academy of Pediatrics and the ACIP do not express a preference for use of MMRV vaccine over separate injections of equivalent component vaccines (MMR and varicella vaccines). 235 Information about changes in recommendations for use of MMRV vaccine can be found at www.cdc.gov/vaccines and www.aapredbook.aappublications.org. The varicella vaccine should be administered to all children in this age range unless there is evidence of immunity to VZV or a contraindication to administration of the vaccine. The second dose of varicella-containing vaccine is recommended routinely when children are 4 through 6 years of age (ie, before a child enters kindergarten or first grade) but can be administered at an earlier age. A routine health maintenance visit at 11 through 12 years of age is recommended for all adolescents to evaluate immunization status and administer necessary vaccines, including the varicella vaccine. People 13 Years of Age or Older People 13 years of age or older without evidence of immunity should receive two 0.5-mL doses of varicella vaccine separated by at least 28 days. The recommendation for at least a 28-day interval between doses is based on the design of the studies evaluating 2 doses in this age group. For people who previously received only 1 dose of varicella vaccine, a second dose is necessary to provide evidence of immunity. Monovalent varicella vaccine, but not MMRV vaccine, is licensed for use in this age group. Contraindications and Precautions Intercurrent Illness As with other vaccines, varicella vaccine should not be administered to people who have moderate or severe illnesses, with or without fever (see Vaccine Safety and Contraindications, p 40). Immunization of Immunocompromised Patients General recommendations. Varicella vaccine should not be administered routinely to children who have congenital or acquired T-lymphocyte immunodeficiency, including people with leukemia, lymphoma, and other malignant neoplasms affecting the bone marrow or lymphatic systems, as well as children receiving long-term

immunosuppressive therapy. An exception includes certain children infected with HIV, as discussed later. Children with impaired humoral immunity may be immunized. Immunodeficiency should be excluded before immunization in children with a family history of hereditary immunodeficiency. The presence of an immunodeficient or HIV-seropositive family member does not contraindicate vaccine use in other family members. When immunizing people with altered immunity against chickenpox, only monovalent varicella vaccine should be used. The Oka vaccine strain remains susceptible to acyclovir, and if a highrisk patient develops vaccine-related varicella, then acyclovir should be used as treatment. Acute lymphocytic leukemia. Before routine immunization of healthy children against varicella was instituted in the United States in 1995, many young children with leukemia were susceptible to chickenpox. To protect them against serious and fatal varicella, a research protocol for immunization against chickenpox was in place, but the protocol has been terminated. Considering the variability of chemotherapy regimens and the current decreasing incidence of varicella in the United States, however, these high-risk children should not be immunized routinely. Immunization of leukemic children without evidence of immunity in remission should be undertaken only with expert guidance and with availability of antiviral therapy should complications occur. Live-virus vaccines usually are withheld for an interval of at least 3 months after immunosuppressive cancer chemotherapy has been discontinued. The interval until immune reconstruction varies with the intensity and type of immunosuppressive therapy, radiation therapy, underlying disease, and other factors. Therefore, it often is not possible to make a definitive recommendation for an interval after cessation of immunosuppressive therapy when live-virus vaccines can be administered safely and effectively. HIV infection. 236 Screening for HIV infection is not indicated before routine VZV immunization. After weighing potential risks and benefits, varicella vaccine should be considered for HIV-infected children with a CD4+ T-lymphocyte percentage of 15% or greater. Eligible children should receive 2 doses of monovalent varicella vaccine with a 3-month interval between doses and return for evaluation if they experience a postimmunization varicella-like rash. With increased use of varicella vaccine and the resulting decrease in incidence of varicella in the community, exposure of immunocompromised hosts to VZV will decrease. As the risk of exposure decreases and more data are generated on the use of varicella vaccine in high-risk populations, the risk versus benefit of VZV immunization in HIV-infected children will need to be reassessed. Children receiving corticosteroids. Varicella vaccine should not be administered to people who are receiving high doses of systemic corticosteroids (2 mg/kg per day or more of prednisone or its equivalent or 20 mg/day of prednisone or its equivalent) for 14 days or more. The recommended interval between discontinuation of corticosteroid therapy and immunization with varicella vaccine is at least 1 month. Varicella vaccine may be administered to people on inhaled, nasal, and topical steroids.

Children with nephrotic syndrome. The results of one small study indicate that 2 doses of the varicella vaccine in 29 children between 12 months and 18 years of age generally were well tolerated and immunogenic, including children receiving low-dose, alternate-day prednisone. Households with potential contact with immunocompromised people. Transmission of vaccinestrain VZV from healthy people has been documented in 5 instances, resulting in 6 secondary cases. Even in families with immunocompromised people, including people with HIV infection, no precautions are needed after immunization of healthy children in whom a rash does not develop. Immunized people in whom a rash develops should avoid direct contact with immunocompromised hosts without evidence of immunity for the duration of the rash. Pregnancy and Lactation Varicella vaccine should not be administered to pregnant women, because the possible effects on fetal development are unknown, although no pattern of malformation has been identified after inadvertent immunization of pregnant women. When postpubertal females are immunized, pregnancy should be avoided for at least 1 month after immunization. A pregnant mother or other household member is not a contraindication for immunization of a child in the household. Reporting of instances of inadvertant immunization with a varicella-zostercontaining vaccine during pregnancy by telephone is encouraged (1-800986-8999). (See Pregnancy, p 7071, and www.merckpregnancyregistries.com/varivax.html). A study of nursing mothers and their infants showed no evidence of excretion of vaccine strain in human milk or of transmission to infants who are breastfeeding. Varicella vaccine should be administered to nursing mothers who lack evidence of immunity. Immune Globulin Whether Immune Globulin (IG) can interfere with varicella vaccine-induced immunity is unknown, although IG can interfere with immunity induction by measles vaccine. Pending additional data, varicella vaccine should be withheld for the same intervals after receipt of any form of IG or other blood product as measles vaccine (see Measles, p 444). Conversely, IG should be withheld for at least 2 weeks after receipt of varicella vaccine. Transplacental antibodies to VZV do not interfere with the immunogenicity of varicella vaccine administered at 12 months of age or older. Salicylates Whether Reye syndrome results from administration of salicylates after immunization for varicella in children is unknown. No cases have been reported. However, because of the association among Reye syndrome, natural varicella infection, and salicylates, the vaccine manufacturer recommends that salicylates be avoided for 6 weeks after administration of varicella vaccine. Physicians need to weigh the theoretical risks associated with varicella vaccine against the known risks of wild-type virus in children receiving long-term salicylate therapy. Allergy to Vaccine Components Varicella vaccine should not be administered to people who have had an anaphylactic-type reaction to any component of the vaccine, including gelatin and neomycin. Most people with allergy to neomycin have resulting contact dermatitis, a reaction that is not a contraindication to immunization. Monovalent varicella vaccine does not contain preservatives or egg protein, and although the measles and mumps vaccines included in MMRV vaccine are produced in chick embryo culture, the amounts of egg cross-reacting proteins are not

significant. Therefore, children with egg allergy routinely may be given MMRV without previous skin testing.

Varicella-Zoster Infections Images

Clinical Manifestations Images See Text

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Image 151_30. Varicella-Zoster Infections Congenital varicella with short-limb syndrome and scarring of the skin. The mother had varicella during the first trimester of pregnancy.

Image 151_57. Varicella-Zoster Infections Varicella embryopathy with involvement of the brain. Atrophy of the left cerebral hemisphere. View larger version (172K): [in this window] [in a new window] [Download PPT slide]

Image 151_73. Varicella-Zoster Infections Varicella lesions on the face of a 4-year old Latin American male View larger version (102K): [in this window] [in a new window] [Download PPT slide]

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Image 151_76. Varicella-Zoster Infections A close-up view of some of the bullous skin lesions of the young adult male in the previous image.

Image 151_74. Varicella-Zoster Infections Varicella lesions in various stages on the left arm and trunk of the 4-year old child in the previous image. Also note the healed vaccination site (scar) of a prior smallpox vaccination

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Image 151_78. Varicella-Zoster Infections Skin lesions in a fatal case of chickenpox (varicella zoster virus) in an immunocompetent young adult

Image 151_40. Varicella-Zoster Infections Herpes zoster lesions in an otherwise healthy child. View larger version (91K): [in this window] [in a new window] [Download PPT slide]

Image 151_80. Varicella-Zoster Infections A White male toddler with hemorrhagic varicella complicating acute lymphocytic leukemia.

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Image 151_49. Varicella-Zoster Infections This boy was treated at New York - Presbyterian Hospital with a lesion on his palatal mucosa due to chickenpox.

Image 151_79. Varicella-Zoster Infections Herpes zoster in an 18 year old white female, a known illicit drug user, who also suffered an anaerobic lung abscess. View larger version (126K): [in this window] [in a new window] [Download PPT slide]

Image 151_59. Varicella-Zoster Infections Varicella lesions in a pre-adolescent male in multiple stages of healing, some of which are covered with calamine lotion

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Image 151_07. Varicella-Zoster Infections School-aged female with varicella who acquired it from a younger sibling who had a more mild clinical course with fewer lesions. View larger version (113K): [in this window] [in a new window] [Download PPT slide]

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Image 151_08. Varicella-Zoster Infections This child acquired her infection from a younger sibling. Varicella lesions are apparent on the palate. This is the same child as in image 151_07.

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Image 151_09. Varicella-Zoster Infections School-aged child with varicella who acquired it from a younger sibling. This is the same child as in images 151_07 and 151_08 who had calamine lotion applied by the parents for itching. She recovered without incident.

Image 151_03. Varicella-Zoster Infections Adolescent white female with varicella lesions in various stages. View larger version (88K): [in this window] [in a new window] [Download PPT slide]

Image 151_04. Varicella-Zoster Infections Varicella with scleral lesions and bulbar conjunctivitis in the same patient as in image 151_03. View larger version (112K): [in this window] [in a new window]

[Download PPT slide]

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Image 151_05. Varicella-Zoster Infections Adolescent white female with varicella lesions in various stages. This is the same patient as in images 151_03 and 151_04.

Image 151_06. Varicella-Zoster Infections Adolescent female with varicella lesions in various stages. This is the same patient as in images 151_03, 151_04, and 151_05. View larger version (97K): [in this window] [in a new window] [Download PPT slide]

Image 151_10. Varicella-Zoster Infections Varicella with erythema multiforme. View larger version (123K): [in this window] [in a new window] [Download PPT slide]

Image 151_11. Varicella-Zoster Infections Varicella with erythema multiforme is the same child as in 151_10. View larger version (98K): [in this window] [in a new window] [Download PPT slide]

Image 151_12. Varicella-Zoster Infections Varicella in a patient with coincidental urticaria pigmentosa lesions. View larger version (90K): [in this window] [in a new window] [Download PPT slide]

Image 151_31. Varicella-Zoster Infections Varicella with bullous lesions. Cultures were negative for bacteria. Scalp lesions are commonly seen early in the course of chickenpox. View larger version (100K): [in this window] [in a new window] [Download PPT slide]

Image 151_32. Varicella-Zoster Infections Varicella with bullous lesions. Cultures were negative for bacteria. This is the same patient as in image 151_31. View larger version (135K): [in this window] [in a new window] [Download PPT slide]

Image 151_34. Varicella-Zoster Infections Varicella with bullous lesions. Blood cultures were negative for bacteria. Cellulitis at sites of bullous lesions resolved while receiving oral dicloxacillin sodium. The child did not appear to be very ill. View larger version (110K): [in this window] [in a new window] [Download PPT slide]

Image 151_33. Varicella-Zoster Infections Varicella with bullous lesions. Cultures of vesicle fluid were negative for bacteria. View larger version (145K): [in this window] [in a new window] [Download PPT slide]

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Image 151_82. Varicella-Zoster Infections Shingles (varicella-zoster virus) in a 13 year old female immunosupressed after bone marrow transplantation.

Image 151_58. Varicella-Zoster Infections Bullous varicella (uncomplicated) in a one-year-old child View larger version (88K): [in this window] [in a new window] [Download PPT slide]

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Image 151_15. Varicella-Zoster Infections Bullous varicella. Staphylococcus aureus organisms may be present in these large bullae.

Image 151_16. Varicella-Zoster Infections Bullous varicella in the same child as in image 151_15. View larger version (83K): [in this window] [in a new window] [Download PPT slide]

Image 151_13. Varicella-Zoster Infections Varicella with secondary thrombocytopenic purpura. View larger version (97K): [in this window] [in a new window] [Download PPT slide]

Image 151_14. Varicella-Zoster Infections Varicella with secondary thrombocytopenic purpura in the same Latin American child as in image 151_13. View larger version (107K): [in this window] [in a new window] [Download PPT slide]

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Image 151_19. Varicella-Zoster Infections A 10-monthold infant on day 5 of a hemorrhagic varicella rash. The infection progressed to Staphylococcus aureus toxinmediated disease with hypotensive shock. The infant recovered with antibiotics and supportive care which included a short course of renal dialysis.

Image 151_81. Varicella-Zoster Infections Papular rash following varicella vaccine administration. View larger version (130K): [in this window] [in a new window] [Download PPT slide]

Image 151_17. Varicella-Zoster Infections Hemorrhagic varicella in a 6-year-old white male with eczema. View larger version (99K): [in this window] [in a new window] [Download PPT slide]

Image 151_18. Varicella-Zoster Infections Healing varicella in a child with eczema. This is the same patient as in image 151_17. View larger version (139K): [in this window] [in a new window] [Download PPT slide]

Image 151_29. Varicella-Zoster Infections Hemorrhagic, disseminated, and fatal varicella with lesions over the anterior chest of a 7-month-old infant. View larger version (115K): [in this window] [in a new window] [Download PPT slide]

Image 151_35. Varicella-Zoster Infections Neonate with hemorrhagic varicella with cellulitis. This infant contracted varicella at birth from his infected mother. View larger version (95K): [in this window] [in a new window] [Download PPT slide]

Image 151_61. Varicella-Zoster Infections Thrombocytopenic purpura complicating varicella in an unimmunized pre-adolescent child. View larger version (111K): [in this window] [in a new window] [Download PPT slide]

Image 151_69. Varicella-Zoster Infections Hemorrhagic Varicella: This is a 10 year old previously normal, unvaccinated male who developed Varicella with disseminated hemorrhagic lesions. His platelet count at tme of presentation was 40,000. He had an uneventful recovery and no underlying disease was found. View larger version (101K): [in this window]

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Image 151_70. Varicella-Zoster Infections Hemorrhagic Varicella: This is a three year old with leukemia who developed varicella with hemorrhagic lesions in association with a low platelet count. View larger version (94K): [in this window] [in a new window] [Download PPT slide]

Image 151_26. Varicella-Zoster Infections Progressive and persistent varicella lesions in a child with acute lymphoblastic leukemia. The child died from disseminated varicella-zoster virus infection despite the administration of varicella-zoster immune globulin. With deficient cellular immunity, varicella lesions often remain vesicular for a prolonged period, may become hemorrhagic, and dissemination of the virus may involve multiple organ systems as View larger version occurred with this child. (93K): [in this window] [in a new window] [Download PPT slide]

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Image 151_27. Varicella-Zoster Infections The same child as in image 151_26 with varicella pneumonia. Note the diffuse nodular lesions and hyperaeration. Pulmonary and generalized visceral involvement was evident at autopsy.

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Image 151_28. Varicella-Zoster Infections Varicella (interstitial) pneumonia. Though rare in otherwise healthy children, this complication of varicella-zoster virus infection in adults accounts for much of the morbidity and mortality caused by the infection.

Image 151_67. Varicella-Zoster Infections Disseminated varicella in a 17-year-old white female with Hodgkin's disease with failure to respond to intravenous acyclovir. View larger version (122K): [in this window] [in a new window] [Download PPT slide]

Image 151_68. Varicella-Zoster Infections Diffuse varicella pneumonia bilaterally shown in the chest radiograph of the above patient with Hodgkin's disease View larger version (104K): [in this window] [in a new window] [Download PPT slide]

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Image 151_20. Varicella-Zoster Infections Varicella in a male child with recent group A streptococcal pharyngitis. The pharyngeal and vesicle cultures were negative for bacteria. The patient had a persistent fever (104.5 F) until penicillin was instituted.

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Image 151_21. Varicella-Zoster Infections Varicella in a child with recent group A streptococcal pharyngitis. There was defervescence of fever and rapid resolution of vesicular lesions following intramuscular administration of procaine penicillin. Cultures of vesicle fluid and blood were negative. This is the same patient as in image 151_20.

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Image 151_22. Varicella-Zoster Infections Varicella complicated by necrotizing fasciitis. A blood culture was positive for group A streptococcus. The disease responded to antibiotics and surgical dbridement followed by primary surgical closure.

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Image 151_23. Varicella-Zoster Infections Varicella and necrotizing fasciitis in the same patient as in image 151_22 shortly after surgical dbridement.

Image 151_24. Varicella-Zoster Infections Varicella and necrotizing fasciitis in the same child as in images 151_22 and 151_23. The child recovered completely, including good surgical healing. View larger version (107K): [in this window] [in a new window] [Download PPT slide]

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Image 151_25. Varicella-Zoster Infections Varicella with early cellulitis of the right perineal area. The patient was treated with intravenous methicillin and promptly responded without surgery, which is often required to avoid tissue necrosis. The blood culture was positive for group A streptococcus.

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Image 151_60. Varicella-Zoster Infections A school-aged female with bilateral periorbital cellulitis and necrotizing fasciitis caused by a group A beta hemolytic streptococcal infection complicating varicella.

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Image 151_48. Varicella-Zoster Infections This is an image of a girl with a secondary skin infection on her face due to chickenpox. Prior to routine varicella vaccine use, the highest incidence of chickenpox was among infants and children 1 - 4 years of age, i.e. 100.4 cases per 1,000 infants and children, probably due to the early exposure to VZV (varicella-zoster virus) in preschool and child care settings in the absence of vaccine protection.

Image 151_36. Varicella-Zoster Infections A young boy with varicella complicated by Staphylococcus aureus impetigo and sepsis. View larger version (107K): [in this window] [in a new window] [Download PPT slide]

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Image 151_37. Varicella-Zoster Infections Varicella in a 12-year-old male with group A streptococcal anterior cervical lymphadenitis and cellulitis of the neck bilaterally.

Image 151_51. Varicella-Zoster Infections Bilateral varicella pneumonia in a child with acute lymphatic leukemia. View larger version (126K): [in this window] [in a new window] [Download PPT slide]

Image 151_64. Varicella-Zoster Infections Varicella in a pregnant adolescent Latin American female. Varicella may be progressive during pregnancy, not infrequently resulting in varicella pneumonia. View larger version (110K): [in this window] [in a new window] [Download PPT slide]

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Image 151_41. Varicella-Zoster Infections Herpes zoster lesions in an otherwise healthy child. The lesions were not particularly painful, as is often the case for immunocompetent children with herpes zoster, particularly in the absence of trigeminal nerve involvement.

Image 151_42. Varicella-Zoster Infections Close-up of the varicella-zoster lesions of the patient in image 151_41.

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Image 151_43. Varicella-Zoster Infections Herpes zoster lesions in an otherwise healthy child. View larger version (118K): [in this window] [in a new window] [Download PPT slide]

Image 151_44. Varicella-Zoster Infections Herpes zoster in an otherwise healthy child. Multiple dermatomes are involved. View larger version (96K): [in this window] [in a new window] [Download PPT slide]

Image 151_45. Varicella-Zoster Infections Herpes zoster in an otherwise healthy child. View larger version (118K): [in this window] [in a new window] [Download PPT slide]

Image 151_62. Varicella-Zoster Infections Crusting varicella-zoster lesions on the left side of the back of an otherwise healthy 12-year old White female. View larger version (111K): [in this window] [in a new window] [Download PPT slide]

Image 151_63. Varicella-Zoster Infections A 14-year-old otherwise healthy Black female with herpes zoster. She had varicella diagnosed at 2 years of age with spontaneous resolution without complications.

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Image 151_38. Varicella-Zoster Infections Varicella zoster in a 7-year-old girl. The patient had an erythematous vesicular skin rash on the face on first examination. The dermatologic distribution suggested the diagnosis of herpes zoster. This image was taken 3 days after acyclovir therapy was initiated. The lesions were crusting. The child had no prior history of recurring infections and was growing well.

Image 151_39. Varicella-Zoster Infections Herpes zoster. Trigeminal nerve involvement. There may be significant pain associated with lesions in the trigeminal nerve distribution. View larger version (115K): [in this window] [in a new window] [Download PPT slide]

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Image 151_46. Varicella-Zoster Infections A 6-year-old girl with medulloblastoma who had completed a course of cranial radiotherapy 6 weeks earlier and before developing varicella-zoster lesions over the distribution of the trigeminal nerve. The patient was admitted and treated with intravenous acyclovir. The skin lesions improved within 24 hours and were completely dry after 5 days of therapy.

Image 151_47. Varicella-Zoster Infections A 6-year-old girl with medulloblastoma complicated by a varicella-zoster infection. This is the same patient as in image 151_46. View larger version (108K): [in this window] [in a new window] [Download PPT slide]

Image 151_65. Varicella-Zoster Infections Severe herpes zoster infection with periorbital cellulitis in an immunocompromised 10year-old white female with a history of varicella at age 3 years. She was treated with intravenous acyclovir with recovery

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Image 151_66. Varicella-Zoster Infections Healing herpes zoster lesions of the 10-year-old immunocompromised child in the previous image who received intravenous acyclovir for 7 days beginning on the third day of the clinical onset View larger version (99K): [in this window] [in a new window] [Download PPT slide]

Image 151_77. Varicella-Zoster Infections Skin lesions in a fatal case of chickenpox (varicella zoster virus) in an immunocompetent young adult. View larger version (87K): [in this window] [in a new window] [Download PPT slide]

Image 151_75. Varicella-Zoster Infections A two year old white male with bullous varicella. Staphylococcus aureus was grown from fluid aspirated from a bullous lesion. View larger version (102K): [in this window] [in a new window] [Download PPT slide] Epidemiology Images See Text

Image 151_56. Varicella-Zoster Infections Number of Varicella cases reported in four states (IL MI TX WV); 1990-2006 View larger version (28K): [in this window] [in a new window] [Download PPT slide] Etiology Images See Text

Image 151_50. Varicella-Zoster Infections Electron micrograph of a Varicella (Chickenpox) Virus. Varicella or Chickenpox, is an infectious disease caused by the varicella-zoster virus, which results in a blister-like rash, itching, tiredness and fever. View larger version (141K): [in this window] [in a new window] [Download PPT slide]

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Image 151_02. Varicella-Zoster Infections Negative-stain electron micrograph of varicella-zoster virus, which causes chickenpox. A viral envelope surrounds the nucleocapsid, which measures approximately 100 nm and is composed of an icosahedron formed by hollow capsomers.

Image 151_01. Varicella-Zoster Infections Transmission electron micrograph of varicella-zoster virions from vesicle fluid of a patient with chickenpox. View larger version (124K): [in this window] [in a new window] [Download PPT slide]

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Image 151_52. Varicella-Zoster Infections This photomicrograph reveals the intranuclear inclusions produced by varicella virus grown in a tissue culture; Magnified 500X. In a laboratory setting, one can observe the presence of multinucleated giant cells along with intranuclear inclusions in cell cultures inoculated with varicella virus.

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229 Centers for Disease Control and Prevention. A new product (VariZIG) for postexposure prophylaxis of varicella available under an investigational new drug application expanded access protocol. MMWR Morb Mortal Wkly Rep. 2006;55. (8): 209210[Medline] 230 Centers for Disease Control and Prevention. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(RR-4):140 231 Centers for Disease Control and Prevention. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(RR-4):140 232 American Academy of Pediatrics, Committee on Infectious Diseases. Prevention of varicella: recommendations for use of varicella vaccines in children, including a recommendation for a routine 2-dose varicella immunization schedule. Pediatrics. 2007;120. (1): 221231[Abstract/Free Full Text] 233 Centers for Disease Control and Prevention. Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine. MMWR Morb Mortal Wkly Rep. 2008;57. (10): 258260[Medline] 234 Centers for Disease Control and Prevention. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008;57(RR-5):130 235 Centers for Disease Control and Prevention. Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine. MMWR Morb Mortal Wkly Rep. 2008;57. (10): 258260[Medline]

236 Centers for Disease Control and Prevention. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Early Release. 2009; 58(March 24, 2009):1207. Available at: http://www.cdc.gov/mmwr/pdf/rr/rr58e324.pdf

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This Article Extract Images Only Services E-mail this link to a friend Add to My File Cabinet Download to citation manager Section 1 Section 2 Section 3 Section 4 Section 5 Appendices Earn CME - What's This? Related Collections Related Articles

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