Chickenpox: Varicella-Virus Infections

VARICELLA-ZOSTER VIRUS INFECTIONS -
DEFINITION
Varicella-zoster virus (VZV) causes two distinct clinical entities: varicella (chickenpox) and
herpes zoster (shingles). Chickenpox, a ubiquitous and extremely contagious infection, is usually
a benign illness of childhood characterized by an exanthematous vesicular rash. With
reactivation of latent VZV (which is most common after the sixth decade of life), herpes zoster
presents as a dermatomal vesicular rash, usually associated with severe pain
Chickenpox
ETIOLOGY
VZV is a member of the family Herpesviridae, ,

DNA VIRUS 180 to 200 nm,
PATHOGENESIS AND PATHOLOGY
Primary Infection
subsequent localized
Transmission is most likely to take place by the respiratory route;
replication of the virus at an undefined site (presumably the nasopharynx) leads to
seeding of the reticuloendothelial system and ultimately to the development of viremia
and skin involvement
Vesicles involve the corium and dermis,
The vesicles either rupture and release their fluid (which includes infectious virus) or are
gradually reabsorbed.
EPIDEMIOLOGY
Humans are the only known reservoir for VZV.
Chickenpox is highly contagious, with an attack rate of at least 90% among susceptible)
individuals.
Persons of both sexes and all races are infected equally often.
The virus is endemic in the population at large; however, it becomes epidemic among susceptible
individuals during seasonal peaksnamely, late winter and early spring in the temperate zone.
CLINICAL MANIFESTATIONS
Children between the ages of 5 and 9 are most commonly affected and account for 50% of all
cases.
Most other cases involve children aged 1 to 4 and those aged 10 to 14.
The incubation period of chickenpox ranges between 10 and 21 days but is usually between 14
and 17 days.
Secondary attack rates in susceptible siblings within a household are between 70 and 90%.
Patients are infectious approximately 48 h prior to the onset of the vesicular rash, during the
period of vesicle formation (which generally lasts 4 to 5 days), and until all vesicles are crusted.
Clinically, chickenpox presents as
 a prodrome 1 to 2 days
 a rash, low-grade fever, and malaise,.
 In the immunocompetent patient, this is usually a benign illness that is associated with
lassitude and with body temperatures of 37.8 to 39.4C (100 to 103F) of 3 to 5 days'
duration.
 The skin lesionsthe hallmark of the infectioninclude maculopapules, vesicles, and

scabs in various stages of evolution
 These lesions, which evolve from maculopapules to vesicles over hours to days, appear
on the trunk and face and rapidly spread to involve other areas of the body.
 Most are small and have an erythematous base with a diameter of 5 to 10 mm.
 Successive crops appear over a 2- to 4-day period.
 Lesions also can be found on the mucosa of the pharynx and/or the vagina.
 Their severity varies from one person to another.
 Some individuals have very few lesions, while others have as many as 2000.
Younger children tend to have fewer vesicles than older individuals.
Secondary and tertiary cases within families are associated with a relatively large number of
vesicles.
Immunocompromised patientsboth children and adults, particularly those with leukemiahave

lesions (often with a hemorrhagic base) that are more numerous and take longer to heal than
those of immunocompetent patients. Immunocompromised individuals are also at greater risk for
visceral complications, which occur in 30 to 50% of cases and are fatal 15% of the time.
COMPLICATIONS
1. secondary bacterial superinfection of the skin, which is usually caused by

Streptococcus pyogenes or Staphylococcus aureus.
2. The most common extracutaneous site of involvement in children is the CNS.
The syndrome of acute cerebellar ataxia and meningeal irritation generally
appears around 21 days after the onset of the rash and rarely develops in the
preeruptive phase
3. Aseptic meningitis, encephalitis, transverse myelitis, Guillain-Barre syndrome,
and Reye's syndrome also can occur
4. Varicella pneumonia is the most serious complication following chickenpox, developing
more commonly in adults (up to 20% of cases) than in children. It usually has its onset 3
to 5 days into the illness and is associated with tachypnea, cough, dyspnea, and fever
5. Other complications of chickenpox include myocarditis, corneal lesions, nephritis,

arthritis, bleeding diatheses, acute glomerulonephritis, and hepatitis.
6. Hepatic involvement, distinct from Reye's syndrome and usually asymptomatic, is
common in chickenpox and is usually characterized by elevated levels of liver enzymes,
particularly aspartate and alanine aminotransferases
Perinatal varicella is associated with a high mortality rate when maternal disease develops within
5 days before delivery or within 48 h thereafter. Because the newborn does not receive protective
transplacental antibodies and has an immature immune system, the illness may be unusually
sever
DIFFERENTIAL DIAGNOSIS
The diagnosis of chickenpox is not difficult. The characteristic rash and a history of recent
exposure should lead to a prompt diagnosis.
Other viral infections that can mimic chickenpox include disseminated
 herpes simplex virus infection in patients with atopic dermatitis and the
 disseminated vesiculopapular lesions sometimes associated with coxsackievirus
infection, echovirus infection, or atypical measles.
PROPHYLAXIS
While chickenpox in the otherwise healthy host is relatively benign, it can cause morbidity and
death.
. A live attenuated varicella vaccine has been licensed and is recommended for administration to
all immunocompetent children and adults at risk of infection
TREATMENT
Medical management of chickenpox in the immunologically normal host is directed toward the
prevention of avoidable complication
good hygiene includes daily bathing and soaks. Secondary bacterial infection of the skin can be
avoided by meticulous skin care, particularly with close cropping of fingernails. Pruritus can be
decreased with topical dressings or the administration of antipruritic drug
Acyclovir --800 mg by mouth five times daily for 5 to 7 days is recommended for adolescents and
adults with chickenpox of 24 h duration.
acyclovir therapy may be of benefit to children 12 years of age if initiated early in the disease
(24 h) at a dose of 20 mg/kg every 6 h
In the immunocompromised host, both chickenpox and herpes zoster (including disseminated
disease) should be treated with intravenous acyclovir, which reduces the occurrence of visceral
complications but has no effect on healing of skin lesions or pain. The dose is 10 to 12.5 mg/kg
every 8 h for 7 days.
Oral acyclovir therapy is not recommended for the treatment of VZV infections in
immunocompromised pati
Herpes Zoster
Herpes zoster, a sporadic disease,
 is the consequence of reactivation of latent VZV from the dorsal root ganglia.
 Most patients have no history of recent exposure to other individuals with VZV infection.
 Herpes zoster occurs at all ages, but its incidence is highest among individuals in the
sixth through the eighth decades of life.
 Recurrent herpes zoster is exceedingly rare except in immunocompromised hosts,
especially those with AIDS.
CLINICAL FEATURE
Herpes zoster, also called shingles, is characterized by
 The onset of disease is heralded by pain within the dermatome that may precede lesions
by 48 to 72 h;
 a unilateral vesicular eruption within a dermatome, often associated with severe pain.
 an erythematous maculopapular rash evolves rapidly into vesicular lesions

 The dermatomes from T3 to L3 are most frequently involved.
 In the normal host, these lesions may remain few in number and continue to form only
for a period of 3 to 5 days.
 If the ophthalmic branch of the trigeminal nerve is involved, zoster ophthalmicus results.
 When branches of the trigeminal nerve are involved, lesions may appear on the face, in
the mouth, in the eye, or on the tongue
 In the Ramsay Hunt syndrome , pain and vesicles appear in the external auditory canal,
and patients lose their sense of taste in the anterior two-thirds of the tongue while
developing ipsilateral facial palsy
 The total duration of disease is generally between 7 and 10 days; however, it may take
as long as 2 to 4 weeks for the skin to return to normal.
 In a few patients, characteristic localization of pain to a dermatome with serologic
evidence of herpes zoster has been reported in the absence of skin lesions.
The factors responsible for the reactivation of VZV are not known.
 In children reactivation is usually benign, whereas in adults it can be debilitating.
 The continuum of pain from onset to resolution is known as zoster-associated pain..
COMPLICATIONS
 The most debilitating complication of herpes zoster, in both the normal and the
immunocompromised host, is pain associated with acute neuritis and postherpetic
neuralgia..
 Changes in sensation in the dermatome, resulting in either hypo- or hyperesthesia,
are common.
 CNS involvement may follow localized herpes zoster
 Cutaneous dissemination
 Among patients with cutaneous dissemination (Fig. 183-CD3), the risk of
pneumonitis, meningoencephalitis, hepatitis, and other serious complications is
increased by 5 to 10%.
Like chickenpox, herpes zoster is more severe in the immunocompromised host than in
the normal individual.
TREATMENT
Patients with herpes zoster benefit from oral antiviral therapy, as evidenced by accelerated
healing of lesions and resolution of zoster-associated pain
1. Acyclovir, 800 mg five times daily for 7 to 10 days
2. Valacyclovir, . The dose is 1 g by mouth three times daily for 5 to 7 days
In the immunocompromised host, both chickenpox and herpes zoster (including disseminated
disease) should be treated with
intravenous acyclovir The dose is 10 to 12.5 mg/kg every 8 h for 7 days.
The management of acute neuritis and/or postherpetic neuralgia .

 analgesics, nonnarcotics or narcotic derivatives,
 gabapentin, amitriptyline hydrochloride, and fluphenazine hydrochloride have been
reported to be beneficial for pain relief.
 Prednisone administered orally was 60 mg/d on days 1 through 7, 30 mg/d on days 8
through 14, and 15 mg/d on days 15 through 21. This regimen is appropriate only for
relatively healthy elderly persons who have moderate or severe pain at presentation

Chickenpox: Varicella-Virus Infections

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VARICELLA-ZOSTER VIRUS INFECTIONS -

VZV is a member of the family Herpesviridae, ,

PATHOGENESIS AND PATHOLOGY

 The skin lesionsthe hallmark of the infectioninclude maculopapules, vesicles, and

Immunocompromised patientsboth children and adults, particularly those with leukemiahave

1. secondary bacterial superinfection of the skin, which is usually caused by

5. Other complications of chickenpox include myocarditis, corneal lesions, nephritis,

 an erythematous maculopapular rash evolves rapidly into vesicular lesions

2. Valacyclovir, . The dose is 1 g by mouth three times daily for 5 to 7 days

The management of acute neuritis and/or postherpetic neuralgia .

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