(Chicken pox)

Infectious and Tropical Pediatric Division,

Department of Child Health,
Medical Faculty, University of Sumatera Utara
Definition : Varicella is a common contagious
disease caused by primary infection with
varicella-zoster virus (VZV). It is
characterized by a short or absent
prodromal period and by a pruritic rash
consisting of crops of papules, vesicles,
pustules, and crusting

Etiology : Varicella zoster virus (VZV)
Herpesvirus group
Epidemiology : worldwide distribution,
usually endemic in large cities. The mostly
age distribution is 5-9 year old.
Transmission by direct contact, droplet.
The patient can transmit the disease 1 day
before the rash appeared until crusted was
dried. In mild cases, crusted was
completed until 5 days, and in severe
cases until 10 days.
Epidemiology of primary varicella
90% of cases occur at <10 years of age; maximum
incidence ages 1-6

Older children more likely to have prodromal symptoms
[Whitney RJ (1990) Antiviral agents and viral diseases of man. Raven Press, NY]

Higher risk of herpes zoster in healthy children infected
with VZV during infancy [Kakourou T et al.(1998) JAAD 39, 207-10; Baba K et al.
(1986) J Pediatr 372-7.]

Highly contagious, with <90% household transmission rate
[Ross AH (1962) NEJM 267, 369-76.]

10-35% transmission rate with secondary contacts like
school [Ross AH (1962) NEJM 267, 369-76.]


Pathogenesis :
Primary varicella
Days 2-4: initial viral replication in
regional lymph nodes
Days 4-6: primary viremia
Subsequent second round of viral
replication in liver, spleen, other organs
Secondary viremia seeds capillaries
and then epidermis by day 14-16
Herpes zoster
VZV spreads from skin/mucosa into
sensory nerve endings
Virus travels to dorsal root ganglion and
becomes latent
Reactivation occurs with decreased cell-
mediated immunity
Initial replication occurs in affected DRG
after reactivation
Ganglionitis ensues, with inflammation
and neuronal necrosis
Pain ensues with travel of the virus
down the sensory nerve
Clinical manifestations :
Incubation period 14-16
days (10-21 days). The
disease begins with
low-grade fever,
malaise, and the
appearance of rash. In
children the exanthem
and symptoms usually
occur simultaneously.
Rash : The typical
vesicle of chickenpox
is superficially located
in the skin. The lesion
appear in crops that
generally involve the
trunk, scalp, face, and
extremities. The
distribution typically
central especially on
trunk and face.

The rash is more profuse on the proximal parts
of the extremities than on the distal parts. A
distinctive manifestation of the eruption is the
presence of lesions in all stages in any one
general anatomical area; macules, papules,
vesicles, pustules, and crusts are usually
located in proximity to each other. In
summary, the rash characterized by (1) a
rapid evolution of macule to papule to vesicle
to pustule to crust, (2) a central distribution of
lesions that appear in crops, and (3) the
presence of lesions in all stages in any one
anatomical area.


Fever : The height of the fever usually
paralels the severity of the rash. When the
eruption is sparse, the temperature is
usually normal or slightly elevated.
Other symptoms : headache, malaise, and
anorexia usually accompany the fever.
The most distressing symptom is pruritus,
which is present during the vesicular stage
of the disease.


Unusual manifestations :
Hemorrhagic, progressive, and disseminated
varicella in immunompromised host and a
potencially fatal outcome. Our department had
been reporting 3 cases with varicella
hemorrhagic, two in immunocompromised
child and the other in normal child.
Congenital varicella syndrome is extremely rare.
Manifestations of this syndrome include a
hypoplastic extremity, zosteriform skin
scarring, microphthalmia, cataracts,
choreoretinitis, and abnormalities of the CNS.

Severe or fatal
varicella in 5 to 10
day-old infants may
occur when their
mothers have
varicella 5 days or
less before delivery.

Diagnosis :
1. Confirmatory clinical factors, (1)
development of a pruritic papulovesicular
eruption concentrated on the face and trunk
associated with fever and mild constitutional
symptoms;
(2) the rapid progression of macules to
papules, vesicles, pustules, and crusts; (3)
the appearance of these lesions in crops,
with a predominant central distribution
including the scalp; (4) the presence of
shallow white ulcers on the mucous
membranes of the mouth; and (5) the
eventual crusting of the skin lesions.
2. Detection of the causative agent from
vesicular fluid
3. Serological tests : ELISA, FAMA, RIA, LA
Differential diagnosis :
Impetigo
Insect bites, papular urticaria, and urticaria
Scabies
Dermatitis herpetiformis
Rickettsialpox
Eczema herpeticum and other forms of HSV
infection
Steven-Johnson syndrome
Smallpox
Chickenpox versus smallpox
CHICKENPOX
14-21 day incubation
Mild to no preceding
illness
Lesions most numerous
on trunk
Palms and soles spared
Lesions at varying stages
of development
Scabs form 4-7 days after
rash appears
Vesicles do collapse on
puncture
SMALLPOX
7-17 day incubation
Fevers, severe systemic
symptoms precede rash
by 2-3 days
Lesions most numerous
on face, arms, legs
Palms and soles involved
Lesions at same stage of
development
Scabs form 10-14 days
after rash appears
Vesicles do not collapse
on puncture
Complications : are not common
Secondary bacterial infection
Encephalitis
Varicella pneumonia
Reyes syndrome
Disseminated varicella

Prognosis : usually a benign disease, clears
spontaneously without sequaelae.
Complications and mortality in
varicella
In healthy children aged 1-14,
mortality rate estimated at 2/100,000
[Mehta PN (2004) eMedicine online]

Bacterial superinfection is most
common complication; Staph
exotoxin can result in bullous
varicella [Melish ME (J Pediatr (1973) 83, 1019-21]
CNS is most common extracutaneous site;
symptoms include Reyes syndrome, acute
cerebellar ataxia, encephalitis, myelitis [McKendall and
Kiawans (1978) Handbook of clinical neurology. Elsevier Press]

Rare complications: myocarditis, appendicitis,
glomerulonephritis, hepatitis, pancreatitis,
vasculitis, arthritis, keratitis, iritis, optic neuritis
Whitney RJ (1990) Antiviral agents and viral diseases of man. Raven
Press, NY]

Immunity : an attack of chickenpox usually
confers lasting immunity.

Treatment : self limited disease
1. Symptomatic acetaminophen for high
fever; oral antihistamines and local
applications of of calamine lotion may help
control the itching. Fingernails should be
kept short and clean in an attempt to
minimize secondary skin infections. For
same reason, daily bathing also
recommended during chickenpox.
2. Treatment of complications :
(1) bacterial infections
(2) encephalitis
3. Specific antiviral : 20 mg/kg of acyclovir four
times daily for 5 days (max 800 mg)
Preventive measures :
Zoster immunoglobulin (ZIG) 5 ml/IM within
72 hours of a household exposure to
children with underlying leukemia.
Live attenuated varicella vaccine.