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Varicella Author Inform

Last Updated: July 1, 2003 Introduction
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AUTHOR INFORMATION Section 1 of 11

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Author: Parang N Mehta, MD, Consulting Staff, Department of Pediatrics, Mehta Contact Derm
Hospital, Surat, India
Coauthor(s): Archana Chatterjee, MD, Assistant Professor, Department of Enteroviral
Pediatrics, Division of Pediatric Infectious Disease, Creighton University Infections

Herpes Simpl
Editor(s): Leonard R Krilov, MD, Chief of Pediatric Infectious Diseases, Virus Infection
Department of Pediatrics, Winthrop University Hospital; Robert Konop, PharmD,
Clinical Assistant Professor, Department of Pharmacy, Section of Clinical Impetigo
Pharmacology, University of Minnesota; Leslie L Barton, MD, Professor, Program
Director, Department of Pediatrics, University of Arizona School of Medicine; Urticaria
Robert W Tolan, Jr, MD, Chief of Pediatric Infectious Diseases, Chairman,
Department of Pediatrics, Capital Health System; Clinical Associate Professor of
Pediatrics, Drexel University College of Medicine; and Russell Steele, MD, Continuin
Department Head and Vice-Chair, Professor, Department of Pediatrics, Division of Educatio
Infectious Diseases, Louisiana State University and New Orleans Children's
CME available
Hospital this topic. Clic
INTRODUCTION Section 2 of 11 here to take th
CME.
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures
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Patient Educ
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Background: Varicella, commonly known in the United States as chickenpox, is patient educa
caused by the varicella-zoster virus. The disease generally is regarded as a mild self-
limiting viral illness with occasional complications. Before vaccination for varicella
became widespread in the United States, this disease caused as many as 100
deaths annually.

Even today, varicella is not totally benign. A recent study suggests that nearly 1 in 50
cases of varicella are associated with complications; among the most dreaded are
varicella pneumonia and encephalitis, both associated with a high mortality rate. In
addition, significant concerns have recently been raised about the association of
varicella with severe invasive group A streptococcal disease.

The United States adopted universal vaccination against varicella in 1995, which
reduced morbidity and mortality from this disease. Children who are not vaccinated,
for various reasons, remain susceptible. Children with varicella expose adult contacts
in households, schools, and daycare centers to the risk of severe, even fatal,
disease. Varicella is common and highly contagious and affects nearly all susceptible
children before adolescence.

Household transmission rates are 80-90%. Second cases within the household often
are more severe. School or daycare center contact is associated with lower but still
significant transmission rates. Susceptible children rarely acquire the disease by
contact with adults with zoster. Maximum transmission occurs during late winter and
spring.

Varicella is associated with humoral and cell-mediated immune responses. These

responses induce long-lasting immunity. Repeat subclinical infection can occur in
these persons, but second attacks of chickenpox are extremely rare in
immunocompetent persons.

Pathophysiology: The varicella-zoster virus enters through the respiratory system

and colonizes the upper respiratory tract. The virus initially replicates in the regional
lymph nodes; 4-6 days later, a primary viremia spreads the virus to
reticuloendothelial cells in the spleen, liver, and elsewhere.

After a week, a secondary viremia disseminates the virus to the viscera and skin,
eliciting the typical skin lesions. This viremia also spreads the virus to respiratory
sites and is responsible for the contagion of varicella before the appearance of the
rash. Infection of the CNS or liver also occurs at this time.

Frequency:

 In the US: Before varicella vaccine use became widespread, 4 million cases
 of chickenpox were reported annually. The disease was responsible for 11,000
hospitalizations each year and approximately 50-100 deaths.

 Internationally: Varicella affects nearly all children who do not have immunity.
Annual incidence is estimated at 80-90 million cases.

Mortality/Morbidity: In otherwise healthy children aged 1-14 years, the mortality rate
is estimated at 2 deaths per 100,000 cases.

 Most deaths in the United States before universal vaccination were from
associated encephalitis, pneumonia, secondary bacterial infection, and Reye
syndrome.

 The mortality rate in children who are immunocompromised is much higher.

 The disease can be serious in neonates, depending on the timing of infection

in the mother.

Race: Varicella has no racial predilection.

Sex: Varicella has no sex predilection.

Age: Maximum incidence of varicella is in children aged 1-6 years. Persons older
than 14 years account for 10% of varicella cases.

CLINICAL Section 3 of 11

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History:

 Exposure

o Varicella spreads primarily by airborne respiratory droplets.

o Most patients have a history of exposure in the home, daycare center,

or school.

 Varicella's incubation period typically is 10-14 days, although it may extend to

21 days.

 Prodrome

o Low-grade fever preceding skin manifestations by 1-2 days

 o Complaints of abdominal pain by some children

o Rash, usually starting on the head and trunk and spreading to the rest
of the body

o Typically, complaints of intense pruritus

o Headache

o Malaise

o Anorexia

o Cough and coryza

o Sore throat

Physical:

 Rash

o The characteristic rash appears in crops.

o An otherwise healthy child usually has 250-500 lesions but may have
as few as 10 or as many as 1500.

o Each lesion starts as a red macule and passes through stages of

papule, vesicle, pustule, and crust.

o Redness or swelling around a lesion should lead to suspicion of

bacterial superinfection.

o The vesicle on a lesion's erythematous base leads to its description as

a pearl or dewdrop on a rose petal.

o Varicella's hallmark is the simultaneous presence of different stages of

the rash.

o Some lesions may appear in the oropharynx.

o Eye lesions are rare.

o New lesions continue to erupt for 3-5 days.

o Lesions usually crust by 6 days (2- to 12-d range), and heal completely
by 16 days (7- to 34-d range).
 o Prolonged eruption of new lesions or delayed crusting and healing can
occur with impaired cellular immunity.

 Fever

o Fever usually is low-grade (100-102°F) but occasionally may be as high

as 106°F.
o In otherwise healthy children, fever typically subsides within 4 days.
o Prolonged fever should prompt suspicion of complication or
immunodeficiency.

 Outcomes of in utero varicella infections vary, based upon the timing of the
infection as follows:

o Congenital varicella syndrome

 Congenital varicella syndrome occurs in 2% of children born to
women who develop varicella during the first or second trimester
of pregnancy.
 This syndrome manifests as intrauterine growth retardation,
microcephaly, cortical atrophy, limb hypoplasia, microphthalmia,
cataracts, chorioretinitis, and cutaneous scarring.
 Fetal injury risk is unrelated to the severity of disease in the
mother.
 Zoster exposure during pregnancy has not been associated with
fetal injury.

o Infantile zoster
 Infantile zoster usually manifests within the first year.
 The cause is maternal varicella infection after the 20th week of
gestation.
 Infantile zoster commonly involves the thoracic dermatomes.

o Neonatal varicella
 Neonatal varicella can be a serious illness, depending upon the
timing of maternal varicella and delivery.
 If the mother develops varicella within 5 days before or 2 days
after delivery, the baby is exposed to the secondary viremia of
the mother. The baby acquires the virus transplacentally but
acquires no protective antibodies because of insufficient time for
antibodies to develop in the mother. In these circumstances,
neonatal varicella is likely to be severe and disseminated.
Prophylaxis or treatment is required with varicella-zoster immune
globulin (VZIG) and acyclovir. Without these drugs, mortality
rates may be as high as 30%. The primary causes of death are
severe pneumonia and fulminant hepatitis.
 Onset of maternal varicella more than 5 days antepartum
 provides the mother sufficient time to manufacture and pass on
antibodies along with the virus. Full-term neonates of these
women usually have mild varicella because of the attenuating
effect of the transplacentally acquired antibodies. Treatment with
VZIG is not recommended in such cases, but acyclovir may be
used, depending on individual circumstances.

Causes:

 Varicella's cause, the varicella-zoster virus, is a member of the human

herpesvirus subfamily Alphaherpesvirinae and, as is true of all herpes viruses,
is a deoxyribonucleic acid (DNA) virus.

 Varicella is highly contagious; secondary attack rates range from 80-90% for
household contacts.

 Transmission

o Transmission occurs mainly by respiratory droplets containing the virus,

making the disease highly contagious even before the rash appears.

o Papules and vesicles, but not the crusts, have high populations of the
virus.

o Varicella's infectious period begins 2 days before skin lesions appear

and ends when the lesions crust, usually 5 days later.

o Direct person-to-person contact with lesions also spreads the virus.

o Maternal varicella with viremia can spread transplacentally to the fetus.

This leads to neonatal varicella.

 Risk factors for severe varicella include the following:

o A neonate's first month of life is a susceptible period for severe

varicella, especially if the mother is seronegative. Delivery before 28
weeks of gestation also renders a baby susceptible because
transplacental transfer of immunoglobulin G (IgG) antibodies occurs
after this time.

o Adolescence and adulthood

o Steroid therapy: High doses (ie, doses equivalent to 1-2 mg/kg/d of

prednisolone) for 2 weeks or more are definite risk factors for severe
disease. Even short-term therapy at these doses immediately
preceding or during the incubation period of varicella can cause severe
 or fatal varicella.

o Malignancy: All children with cancer have an increased risk for severe
varicella. The risk is highest for children with leukemia. Almost 30% of
patients who are immunocompromised and who have leukemia have
visceral dissemination of varicella; 7% may die.

o Immunocompromised state (eg, malignancy, antimalignancy drugs, HIV,

other congenital or acquired immunodeficient conditions): Defects of
cellular but not humoral immunodeficiency are believed to render a
person susceptible to severe varicella.

o Pregnancy: Pregnant women have high risk of severe varicella,

especially pneumonia.

DIFFERENTIALS Section 4 of 11

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Contact Dermatitis
Enteroviral Infections
Herpes Simplex Virus Infection
Impetigo
Urticaria

Other Problems to be Considered:

Drug reactions
Insect bites
Smallpox

WORKUP Section 5 of 11

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Lab Studies:

 Laboratory studies are unnecessary for diagnosis because varicella is obvious clinically.

 Most children with varicella have leukopenia in the first 3 days, followed by leukocytosis.

 Marked leukocytosis may indicate a secondary bacterial infection, but this is not a dependable
Most children with significant secondary bacterial infections do not have leucocytosis.
  Immunohistochemical staining of skin lesion scrapings can confirm varicella.

o The procedure is useful for high-risk patients who require rapid confirmation.

o A Tzanck smear involves scraping the base of the lesions, then staining the scrapings
demonstrate multinucleated giant cells. This finding, however, is not sufficiently sensitiv
specific for varicella and should be replaced by the more specific immunohistochemica
staining of such scrapings, if available.

 Serologic studies

o Serology mainly is used to confirm past infection to assess a patient's susceptibility sta
This helps determine preventive treatment requirements for an adolescent or adult who
been exposed to varicella.

o Among the many serologic studies, the most sensitive are the indirect fluorescent antib
(IFA), fluorescent antibody to membrane antigen (FAMA), neutralization test (NT), and
radioimmunoassay (RIA). These time-consuming tests require specialized equipment t
renders them unsuitable for routine use.

o Commercially available latex agglutination (LA) and enzyme-linked immunosorbent ass

(ELISA) tests are sensitive and rapid. Although the complement fixation test often is us
sensitivity is low.

Imaging Studies:

 Chest x-ray

o Children with high temperatures and respiratory signs should have a chest x-ray to con
exclude pneumonia.

o Chest x-ray findings may be normal or may show diffuse bilateral nodular infiltrates in p
varicella pneumonia. X-rays also may detect focal infiltrates suggestive of secondary b
pneumonia.

Other Tests:

 Lumbar puncture

o Children with neurological signs should have their cerebrospinal fluid (CSF) examined.

o The CSF of patients with varicella encephalitis may have few or as many as a hundred
that are polymorphonuclear or mononuclear, depending on the timing of the lumbar pu

 Glucose levels are normal.

  Protein levels are normal or slightly raised.

TREATMENT Section 6 of 11

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Medical Care:

 Manage pruritus with cool compresses and regular bathing.

 Discourage scratching to avoid scarring. Trimming the child's fingernails and having the child
mittens while sleeping may reduce scratching.

Consultations:

 Consult with an infectious disease specialist in the following situations:

o Progressive or severe varicella

o Life-threatening complications (eg, encephalitis, pneumonia)

o Serious secondary bacterial infections, especially group A streptococcal superinfection

which may evolve rapidly into necrotizing fasciitis and toxic shock syndrome

 Children who develop severe and life-threatening varicella complications may require hospita
in an ICU.

Diet:

 Advise parents to provide a full and unrestricted diet to the child.

 Some children with varicella have reduced appetite and should be encouraged to take sufficie
fluids to maintain hydration. Adequate hydration is especially important if the child is receiving
acyclovir, as the drug can crystallize in the renal tubules if administered to dehydrated individu

Activity: No activity restrictions are needed for young children with uncomplicated varicella.

MEDICATION Section 7 of 11

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Drug Category: Antivirals -- Chickenpox is not always benign. In certain well-defined groups, varicella c
severe and even fatal. Antiviral drugs are recommended for adolescents, adults, and children on steroid or salic
therapy and for children who are otherwise immunocompromised. Acyclovir is the only adequately studied dru
this class.

Acyclovir (Zovirax) -- Antiviral that acts by inhibiting

herpes virus DNA polymerase and terminating viral
replication. It reduces the number of lesions and
duration of fever if started within 24 h of appearance of
rash. In young children with uncomplicated varicella,
benefit is only marginal and use is not routinely
Drug Name recommended. It does not affect incidence of pruritus,
complications, or secondary transmission. It is always
used for complications of varicella (eg, encephalitis,
pneumonia) and for immunocompromised individuals
with varicella. Available as 200 and 800 mg capsules,
400 mg/5 mL oral liquid, and 500 mg/mL parenteral
injection.
800 mg PO 5 times/d for 7 d
1500 mg/m2/d IV divided q8h for 7-10 d for
Adult Dose
encephalitis, pneumonia, or infection in
immunocompromised patients
80 mg/kg/d PO divided in 4-5 doses for 5 d; not to
Pediatric Dose exceed 3200 mg/d
Encephalitis or pneumonia: Administer as in adults
Contraindications Documented hypersensitivity
Concomitant use of probenecid or zidovudine prolongs
Interactions
half-life and increases CNS toxicity of acyclovir
Pregnancy B - Usually safe but benefits must outweigh the risks.
Caution in renal failure or when using nephrotoxic
drugs; may cause malaise, GI upset, and rash; oral
Precautions bioavailability is poor, making IV administration
essential for patients with severe varicella and for
immunocompromised patients

Drug Category: Antipyretics -- Inhibits central synthesis and release of prostaglandins that mediate the e
endogenous pyrogens in the hypothalamus, thus, promotes the return of the set-point temperature to normal.
Fever usually is low grade but may be elevated. Acetaminophen probably is the safest drug to use for this purp
Salicylate usage for varicella is associated with Reye syndrome; therefore, never prescribe these agents. Nonst
anti-inflammatory drugs (NSAIDs) have been suspected of suppressing immune function and promoting infec
progress in patients infected with invasive group A streptococci.

Drug Name Acetaminophen (Tylenol, Feverall, Tempra, Aspirin-

Free Anacin) -- DOC as has no association with Reye
syndrome; available as gtt containing 80 mg/0.8 mL,
 susp containing 160 mg/5 mL, chewable tab or cap
containing 80 mg, and tab containing 160 mg, 325 mg,
and 500 mg.
500-650 mg/dose PO q4-6h prn for fever; not to
Adult Dose
exceed 4 g/d
10-15 mg/kg PO q4-6h prn for fever; not to exceed 60
Pediatric Dose
mg/kg/d
Contraindications Documented hypersensitivity
Rifampin can reduce analgesic effects of
acetaminophen; coadministration with barbiturates,
Interactions
carbamazepine, hydantoins, and isoniazid may
increase hepatotoxicity
Pregnancy B - Usually safe but benefits must outweigh the risks.
Hepatotoxicity possible in persons with chronic
alcoholism following various dose levels; severe or
recurrent pain or high or continued fever may indicate
Precautions a serious illness; contained in many OTC products and
combined use with these products may result in
cumulative acetaminophen doses exceeding
recommended maximum dose
Ibuprofen (Motrin, Ibuprin) -- A propionic acid
derivative NSAID; acts by inhibiting prostaglandin
synthesis; also has anti-inflammatory and analgesic
Drug Name
properties; available as an oral suspension (100 mg/5
mL) and tablets containing 300 mg, 400 mg, 600 mg,
or 800 mg.
Adult Dose 200-400 mg PO q4-6h prn for fever
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid; not
Pediatric Dose to exceed 40 mg/kg/d
>12 years: Administer as in adults
Documented hypersensitivity; peptic ulcer disease,
Contraindications recent GI bleeding or perforation; renal insufficiency;
high risk of bleeding
Interactions Coadministration with aspirin increases risk of
inducing serious NSAID-related adverse effects;
probenecid may increase concentrations and,
possibly, toxicity of NSAIDs; may decrease effect of
hydralazine, captopril, and beta-blockers; may
decrease diuretic effects of furosemide and thiazides;
monitor PT closely (instruct patients to watch for signs
of bleeding); may increase risk of methotrexate
toxicity; phenytoin levels may be increased when
 administered concurrently
C - Safety for use during pregnancy has not been
Pregnancy
established.
Category D in third trimester of pregnancy; caution in
congestive heart failure, hypertension, and decreased
renal and hepatic function; caution in anticoagulation
abnormalities or during anticoagulant therapy; causes
Precautions
nausea, stomach upset, and rashes in 3-9% of
patients; causes maculopapular rash and pruritus in 1-
3% of recipients; may confuse clinical picture of
varicella

Drug Category: Antihistamines -- May control pruritus by blocking effects of endogenous release of his
Pruritus can be severe in varicella, preventing sleep and possibly leading to scarring or secondary infection.
Nonsedating antihistaminics lack sufficient antipruritic action. The value of local preparations (eg, calamine,
antihistamines) is unproved. Topical antihistamines can cause significant sedation from absorption through inj
skin.

Diphenhydramine (Benadryl) -- Antihistamine has a

sedating effect and is effective for pruritus; available
Drug Name as a liquid containing 12.5 mg/5 mL, capsules
containing 25 and 50 mg, and injections containing 10
and 50 mg/mL.
Adult Dose 25-50 mg PO tid/qid
Pediatric Dose 5 mg/kg/d PO divided tid/qid; not to exceed 300 mg/d
Contraindications Documented hypersensitivity; MAOIs
Potentiates effect of CNS depressants; because of
alcohol content, do not administer syrup form to
Interactions
patient taking medications that can cause
disulfiramlike reactions
Pregnancy B - Usually safe but benefits must outweigh the risks.
May exacerbate angle-closure glaucoma,
Precautions hyperthyroidism, peptic ulcer, and urinary tract
obstruction
FOLLOW-UP Section 8 of 11

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Further Inpatient Care:

 Indications for admission to ICU/neonatal ICU

 o Altered consciousness

o Seizures

o Difficulty walking

o Respiratory distress

o Cyanosis

o Low oxygen saturation

 Hospitalize and treat all newborns whose mothers developed varicella less than 5 days before
within 2 days after delivery.

Deterrence/Prevention:

 Vaccination

o Varicella vaccine consists of live attenuated Oka strain varicella virus. The vaccine is s
highly immunogenic.

o Protection against varicella ranges from 71-100% and is likely to be long term. Breakth
varicella is mild when it occurs.

o The vaccine is effective when administered on or after the age of 1 year. Only a single
recommended for children younger than 13 years. For older children, the recommende
dosage is 2 doses separated by 4-8 weeks.

o Research study protocols allow varicella vaccine administration to patients with leukem
while they are in remission.
o Postexposure prophylaxis, if provided within 72 hours of contact, can prevent or attenu
disease in the exposed individual.

 Varicella-zoster immune globulin

o VZIG is used as postexposure prophylaxis in high-risk individuals. Administration as so

possible after exposure is best, but VZIG can prevent or attenuate varicella if administe
within 96 hours of contact.
o The dose is 125 U/10 kg body weight; 125 U is the minimum dose. Maximum dose is 6
o VZIG is administered IM, never IV. The expected duration of protection is approximatel
weeks. Patients on replacement IV immunoglobulin (IVIG) do not need VZIG if their mo
recent IVIG infusion was within 3 weeks.

o VZIG reduces complications and the mortality rate of varicella, not its incidence.
Postexposure prophylaxis using varicella vaccine is preferred for immunologically norm
 patients. VZIG is indicated for the following persons with significant exposure:
 Newborns of mothers who acquired varicella 5 days before to 2 days after delive
 Children with leukemia or lymphoma who have not been vaccinated and have n
varicella previously
 Persons with HIV, AIDS, or other immunodeficiency disorders
 Persons receiving drugs that suppress immune function (eg, systemic steroids)
 Pregnant women
 Immunocompromised individuals who have no reliable history of chickenpox

 The American Association of Pediatrics (AAP) Red Book recommends excluding affected chil
from school until the sixth day of rash. This may not prevent spread of varicella because the c
infective before rash appears.

Complications:

 Secondary bacterial infections

o Varicella may predispose patients to bacterial infections. Skin lesion infections are com
and occur in 5-10% of children. Skin lesions provide a portal of entry for virulent organi
rapidly spreading cellulitis, septicemia, and other serious infections may occur.
o The most common infectious organisms are group A streptococci and Staphylococcus
aureus. Varicella places the patient at high risk for acquiring invasive group A streptoco
disease. In addition to toxic shock syndrome, group A streptococci may cause necrotiz
fasciitis, bacteremia, osteomyelitis, pyomyositis, gangrene, subgaleal abscess, arthritis
meningitis in patients with varicella.
o Staphylococcal species also cause severe infections in children with varicella. Staphylo
infections in these patients reportedly cause cellulitis, impetiginous pox infections,
staphylococcal scalded skin syndrome, toxic shock syndrome, pericarditis, and osteom
o Signs and symptoms of secondary bacterial infection can be indistinguishable from
uncomplicated varicella during the first 3-4 days.
o A high level of suspicion is necessary for early recognition and timely appropriate treatm
secondary infections.
o Suspect secondary infection when systemic manifestations do not improve in 3-4 days
fever returns or worsens, or the child's condition deteriorates after initial improvement.
o Suspicion of secondary bacterial infection should prompt early institution of empirical
antibiotic therapy until the results of culture studies become available.
o Neutrophilic leukocytosis and neutrophilia occur in only a few cases involving serious
bacterial infections.
o Investigations cannot be relied upon to diagnose or exclude bacterial infection.

 CNS complications

o Acute postinfectious cerebellar ataxia is the most common CNS complication, with an
incidence of 1 case per 4000 patients with varicella.
 Ataxia has sudden onset that usually occurs 2-3 weeks after the onset of varice
condition may persist for 2 months.
  Manifestations may range from mild unsteadiness to complete inability to stand
walk, with accompanying incoordination and dysarthria. Manifestations are max
onset; a waxing and waning course suggests another diagnosis.
 The sensorium is clear, even when the ataxia is profound.
 The prognosis for patients with ataxia is good, but a few children may have resid
ataxia, incoordination, or dysarthria.
o Encephalitis occurs in 1.7 patients per 100,000 cases of varicella among otherwise hea
children aged 1-14 years.
 The disease manifests during acute varicella a few days after rash onset. Letha
drowsiness, and confusion are the usual presenting symptoms.
 Some children may have seizures, and encephalitis can progress rapidly to dee
coma.
 This serious complication of varicella has a 5-20% mortality rate.
o Reye syndrome was associated with varicella when aspirin use was common. Identific
this association now has made acetaminophen the preferred drug, and Reye syndrome
become rare.
o Other neurological complications are aseptic meningitis, Guillain-Barré syndrome, and
polyradiculitis.

 Pneumonia
o Pneumonia occurs primarily among older children and adults and can have a fatal outc
o Respiratory symptoms usually appear 3-4 days after the rash.

 Herpes zoster
o A delayed complication of varicella, herpes zoster infection, occurs months to years aft
primary infection in about 15% of patients.
o The complication is caused by virus persisting in the sensory ganglions.
o Herpes zoster consists of a unilateral vesicular rash, limited to 1-3 dermatomes. The ra
often is painful in older children and adults. Among the health benefits of routine varice
immunization in childhood may be a lifelong decreased risk for reactivation of the virus
shingles.

 Otitis media: About 5% of children with varicella develop otitis media, caused by the usual
pathogens.

 Thrombocytopenia
 Hepatitis is a self-limited accompaniment of varicella.

o Severe hepatitis with clinical manifestations is infrequent in otherwise healthy children

varicella.
o Significant elevations of alanine aminotransferase (ALT) occur in 20-50% of children an
adolescents, but elevations return to normal within 1 month in almost all cases.
o Liver involvement is independent of the severity of skin and systemic manifestations.

 Glomerulonephritis
 Hemorrhagic varicella
Prognosis:

 Otherwise healthy children with varicella have excellent prognoses.

 Children with immunocompromised states are at risk for severe disease and death (eg, the m
rate among children with leukemia is 7%).

 Neonatal varicella mortality rates can reach 30%.

 An episode of varicella confers immunity. Second episodes are exceedingly rare.

Patient Education:

 Bathe the child regularly to reduce itching and prevent secondary infection.

 Scratching can lead to secondary infection and scarring.

o Keep the fingernails short.

o Wearing mittens or socks on the hands at night can help prevent scratching.

 Do not use medications containing aspirin.

 Advise parents to take children to the hospital if the following symptoms occur:

o Unusual redness, swelling, or pain over an area of the rash

o Refusal to drink fluids
o Signs of dehydration, such as scanty and yellow-colored urine, increasing drowsiness,
mouth and lips, excessive thirst, or lethargy

o Confusion, irritability, drowsiness, or difficulty waking

o Inability to walk or unusual weakness
o Complaints of severe headache, stiff neck, and/or back pain

o Frequent vomiting
o Difficulty breathing, chest pain, wheezing, fast breathing, or severe cough
o Fever persisting more than 4 days or fever returns after defervescence

o A more sickly appearance than when last seen by the doctor

MISCELLANEOUS Section 9 of 11

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Medical/Legal Pitfalls:

 Early recognition of secondary bacterial infection and appropriate follow-up are major issues.
to recognize occult infection may result in serious illness and even death.

 Isolate patients with varicella because the disease is highly contagious and airborne spread c
occur. Isolation is especially important if the hospital also admits patients who are
immunocompromised because their exposure to the disease can be serious and even fatal.

Special Concerns:

 Pregnancy is a particularly susceptible time. Varicella can cause various adverse outcomes fo
mother and infant, depending on the stage of pregnancy.

 Immunocompromised children often have severe and complicated varicella, and their mortalit
is higher than that in immunocompetent children. Consider the following categories of patients
immunocompromised:

o Children with any malignancy

o Children on cancer chemotherapy
o Children undergoing high-dose corticosteroid therapy
o Children with congenital cellular immunodeficiencies
o Children on immunosuppressive therapy
o Children with HIV infection

 Skin diseases: Children with eczema or dermatitis may have severe skin manifestations durin
varicella.

PICTURES Section 10 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Caption: Picture 1. The pleomorphic rash characteristic of varicella. Papules,

vesicles, and pustules exist concurrently.

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BIBLIOGRAPHY Section 11 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
  Arbeter AM, Granowetter L, Starr SE: Immunization of children with acute lymphoblastic leuke
with live attenuated varicella vaccine without complete suspension of chemotherapy. Pediatric
Mar; 85(3): 338-44[Medline].
 Buchholz U, Moolenaar R, Peterson C: Varicella outbreaks after vaccine licensure: should the
make you chicken? Pediatrics 1999 Sep; 104(3 Pt 1): 561-3[Medline].
 Derrick CW Jr, Lord L: In utero varicella-zoster infections. South Med J 1998 Nov; 91(11): 106
6[Medline].
 Dowell SF, Bresee JS: Severe varicella associated with steroid use. Pediatrics 1993 Aug; 92(2
8[Medline].
 Infectious Diseases and Immunization Committee, Canadian Paediatric Society: Chicken pox
prevention and treatment. The Canadian Journal of Paediatrics 1994; 1: 88-96.
 Jaamaa S, Salonen M, Seppala I I, et al: Varicella zoster and Borrelia burgdorferi are the main
agents associated with facial paresis, especially in children. J Clin Virol 2003 Jul; 27(2): 146-1
 Kouwabunpat D, Hoffman J, Adler R: Varicella complicated by group A streptococcal sepsis a
osteonecrosis. Pediatrics 1999 Oct; 104(4 Pt 1): 967-9[Medline].
 MMWR Morb Mortal Wkly Rep: Prevention of varicella. Update recommendations of the Advis
Committee on Immunization Practices (ACIP). 1999 May 28; 48(RR-6): 1-5[Medline].
 Pastuszak AL, Levy M, Schick B: Outcome after maternal varicella infection in the first 20 wee
pregnancy. N Engl J Med 1994 Mar 31; 330(13): 901-5[Medline].
 Starr SE: Status of varicella vaccine for healthy children. Pediatrics 1989 Dec; 84(6): 1097-
9[Medline].

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