Varicella (Chicken Pox)

Varicella
 Varicella (chickenpox) – primary infection

 Varicella (chickenpox)

– primary infection
Herpes zoster (shingles
(shingles)) – recurrent form

 Herpes zoster (shingles)

– recurrent form
 Etiology
 Varicella – Zoster (DNA virus)

 Humans – only reservoir

 Only one serotype is known
 Epidemiology

 attack rate of at least 90% among susceptible

(seronegative) individuals
 children 5–9 years - 50% of all cases
 Incubation Period: 10-
21 days
 Mode of Transmission
 by respiratory droplets
 direct contact
 linen or fomites
 vertical transmission
during pregnancy
 Contagious
 A day before eruptions
 Until all vesicles are crusted (5-6th day)

 Immunity – long lasting

Pathophysiology

VZV transmission

inoculation of virus onto the mucosa of URT and

tonsillar lymphoid tissue

Primary Viremic Phase

Secondary Viremic Phase

VZV to upper respiratory
mucosal sites

Vesicular lesions
 Clinical Manifestations
 In healthy children, the disease is generally mild
 IP
 Fever – usually low grade preceding skin manifestation
 malaise, anorexia, headache, cough, runny nose, decreased
appetite
 Superficial vesicular lesions
 “dewdrop on a rose petal”
 Pruritic
 Trunk, face or trunk  centrifugal
 All developmental stages of the rash are present at the
same time
 Laboratory
 Viral Isolation
 Vesicular scrapings (Tzanck smear) - multi-
nucleated giant cells, consistent with VZV and
herpes simplex virus (HSV) infection.
 fluorescent monoclonal antibody test - very
sensitive and specific
 Serologic Testing --
 Antibody Tests:
 Complement fixation (CF): Commercially available, but
lacks sensitivity.
 Neutralization test (NT): Sensitive and specific; time
consuming and difficult to perform; not readily available.
 Immunofluorescence assay for antibody to VZV-induced
membrane antigen (FAMA): sensitive, time consuming,
not readily available.
 Immune adherence hemagglutination (IAHA) sensitive; not
readily available.
 Enzyme-linked immunosorbent assay (ELISA): Sensitive,
simple, and commercially available; may be useful for
routine testing.
 Treatment
 Healthy children
 no medical treatment
 antihistamine to relieve itching
 Oral therapy with acyclovir (20 mg/kg/dose, maximum 800
mg/dose) given as 4 doses/day for 5 days should be used to treat
uncomplicated varicella
 IV Acyclovir (nucleoside analogues)
 < 1 yr 30 mg/kg/day in 3 divided doses for 7-10 days
 > 1 yr 1500 mg/m2/day divided q 8 h for 7-10 days
 Immunocompromised patients
 Patients being treated with chronic corticosteroids
 medications to shorten the duration of the infection
 help reduce the risk of complications

Recommendations of the Advisory Committee on Immunization Practices. MMWR 2006;55:209-210.

 Valacyclovir and Famciclovir
 approved for use only in adults

 Don't give Aspirin : Reye's syndrome.

 Complications of Varicella
 herpes zoster (shingles)
 lifetime risk 15%-20%
 mainly affecting the
elderly and
immunocompromised
persons
 secondary bacterial skin and
soft tissue infections
 otitis media
 bacteremia, pneumonitis
 osteomyelitis
 septic arthritis
 endocarditis
 necrotizing fasciitis
 toxic shock-like syndrome
 hepatitis
 thrombocytopenia hemorrhagic
varicella
 cerebellar ataxia
 encephalitis
 severe invasive group A
streptococcal infection
increases the risk 40-60 fold
 Prevention
 Live virus varicella vaccine - monovalent
vaccine
 Measles, mumps, and rubella (MMR) vaccine
 Prevention
 VZIG
 Dose: 125 units/I0 kg, up to a maximum of 625
units (five vials), IM. Volume 125 units per 1.25
ml (one vial).
 Should be given within 96 hours of exposure,
preferably as soon as possible
 Varicella Vaccine
 Oka strain
 between 12 and 15 months
 booster shot at 4 to 6 years of age
 7-13 years - who have not had chickenpox
may also receive the vaccine, with the two
doses given at least 3 months apart.
 ≥ 13 years who have not had either chickenpox
or the vaccine need two vaccine doses at least
1 month apart.
 Zoster
 Reflects reactivation of latent VZV infection.
 Reactivation is associated with aging,
immunosuppression, in utero exposure to
varicella, and postnatal varicella occurring
before 18 months of age
 occurs unilaterally in
the distribution of the
dermatomes supplied by
a dorsal root or
extramedullary cranial
nerve sensory ganglion.
 Complication – herpetic
neuralgia