Varicella Zoster (Chickenpox)


Article Author:
Folusakin Ayoade


Article Editor:
Sandeep Kumar


Editors In Chief:
Lauren Camaione


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
11/23/2018 10:35:54 AM

Introduction

Chickenpox or varicella is a contagious disease caused by the varicella zoster virus (VZV). The virus is responsible for chickenpox (usually primary infection in non-immune hosts) and herpes zoster or shingles (following reactivation of latent infection). Chickenpox results in a skin rash that forms small, itchy blisters, which scabs over. It typically starts on the chest, back, and face then spreads. It is accompanied by fever, fatigue, pharyngitis, and headaches which usually last five to seven days. Complications include pneumonia, brain inflammation, and bacterial skin infections. The disease is more severe in adults than in children. Symptoms begin ten to 21 days after exposure, but the average incubation period is about two weeks.

Chickenpox is a worldwide, airborne disease that is spread by coughing and sneezing, and also by contact with skin lesions. It may start to spread one to two days before the rash appears until all lesions are crusted over. Patients with shingles may spread chickenpox to those who are not immune through blister contact. The disease is diagnosed based on the presenting symptoms and confirmed by polymerase chain reaction (PCR) testing of the blister fluid or scabs. Tests for antibodies may be performed to determine if immunity is present. Although reinfections by varicella may occur, these reinfections are usually asymptomatic and much milder than the primary infection.

The varicella vaccine was introduced in 1995 and has resulted in a significant decrease in the number of cases and complications. It prevents about 70% to 90% of infections and 95% of severe disease. Routine immunization of children is recommended. Immunization within three days of exposure may still improve outcomes in children. [1][2][3]

Etiology

Chickenpox or varicella is caused by the varicella zoster virus (VZV), a herpesvirus with worldwide distribution. It establishes latency after primary infection, a feature unique to most herpes viruses. [4]

Epidemiology

Varicella occurs in all countries and is responsible annually for about 7000 deaths. In temperate countries, it is a common disease of children, with most cases occurring during the winter and spring. In the United States, it accounts for more than 9000 hospitalizations annually. Its highest prevalence is in the 4 to 10-year-old age group. Varicella has an infection rate of 90%. Secondary cases in household contacts tend to have more severe disease than primary cases. In the tropics, varicella tends to occur in older people and may cause more serious disease. Adults will get deep pock marks and more prominent scars.[5][6][7]

Pathophysiology

Exposure causes the production of host immunoglobulin G, M, and A. IgG antibodies persist for life and confer immunity. Cell-mediated immune responses are important in limiting the duration of primary varicella infection. After primary infection, it is theorized varicella spreads to mucosal and epidermal lesions to local sensory nerves. It then remains latent in the dorsal ganglion cells of the sensory nerves. The immune system keeps the virus in check but reactivation can still occur later in life and results in the clinically distinct syndrome of herpes zoster (shingles), postherpetic neuralgia, and sometimes Ramsay Hunt syndrome type II. Varicella zoster can harm the arteries in the neck and head, resulting in a stroke.

The United States Advisory Committee on Immunization Practices (ACIP) suggests that all adult older than the age of 60 years old get vaccinated to avoid herpes zoster. One in five adults who had chickenpox as children, especially those who are immune-suppressed,  get singles. Shingles are most commonly found in adults older than the age of 60 who were diagnosed with chickenpox before the age of 1.[8][9]

History and Physical

The prodromal symptoms in adolescents and adults are aching muscles, nausea, decreased appetite, and headache followed by a rash, oral sores, malaise, and a low-grade fever. Oral manifestations may precede the skin rash. In children, the illness may not be preceded by prodromal symptoms, and the initial sign could be a rash or oral cavity lesions. The rash begins as small red dots on the face, scalp, torso, upper arms and legs. Over the next ten to 12 hours it progresses to small bumps, blisters, and pustules; and eventually umbilication and scabs formation. Of note, the rash of chickenpox occur in crops and are typically at different stages of evolution.

At the blister stage, intense pruritus is present. Blisters may occur on the palms, soles, and genital area. Commonly, visible evidence develops in the oral cavity and tonsil areas in the form of small ulcers which can be painful and itchy; this enanthem may precede the external exanthem by one to three days. These symptoms appear ten to 21 days after exposure. Adults may have a more widespread rash and longer fever, and they are more likely to develop pneumonia, the most important complication in adults.

Because watery nasal discharge containing live virus precedes exanthems by one to two days, the infected person is contagious one to two days before recognition of the disease. In the majority of cases, the infection resolves itself within two to four weeks.

Evaluation

The diagnosis of varicella infection is primarily based on the signs and symptoms. Confirmation is by examination of the fluid within the vesicles, scraping of lesions that have not crusted or by blood for evidence of an acute immunologic response. Polymerase chain reaction (PCR) has the highest yield and can be utilized for non-skin samples such as bronchoalveolar lavage sample and cerebrospinal fluid. Direct fluorescent antibody testing has largely replaced the Tzanck test. The vesicular fluid can also be cultured, but the yield is low compared to PCR.  Blood tests are used to identify a response to acute infection (IgM), previous infection, and subsequent immunity (IgG). Prenatal diagnosis of fetal varicella can be performed using ultrasound, though a delay of 5 weeks following primary maternal infection is advised. A PCR (DNA) test of the amniotic fluid can be performed, though the risk of spontaneous abortion due to amniocentesis is higher than the risk of the baby developing fetal varicella. [10][11]

Treatment / Management

Treatment is symptomatic relief of symptoms. As a protective measure, those infected are usually required to stay at home while they are infectious. Keeping nails short and wearing gloves may prevent scratching and reduce the risk of secondary infections. [12][13][1]

Topical calamine lotion may relieve pruritus. Daily cleansing with warm water will help avoid secondary bacterial infection. Acetaminophen may be used to reduce fever. Avoid aspirin as it may cause Reye syndrome. People at risk of developing complications and who have had significant exposure may be given intramuscular varicella zoster immune globulin, a preparation containing high titers of antibodies to varicella zoster virus, to help prevent the disease.[14]

  • In children, acyclovir decreases symptoms by one day if taken within 24 hours of the start of the rash, but it has no effect on complication rates, and it is not recommended for individuals with normal immune function.
  • In adults, infection tends to be more severe, and treatment with antiviral drugs (acyclovir or valacyclovir) is advised if they can be started within 24 to 48 hours of rash onset. Supportive care such as increasing water intake and the use of antipyretics and antihistamines is an important part of the management. Antivirals are typically indicated in adults, including pregnant women because this group is more prone to complications. The preferred treatment is usually oral therapy, but for immunocompromised patients, intravenous antivirals are indicated.

Differential Diagnosis

  • Insect bites
  • Impetigo
  • Small pox
  • Drug eruptions
  • Dermatitis herpetiformis

Consultations

  • Pediatrician
  • Infectious disease consultant

Pearls and Other Issues

Chickenpox is rarely fatal. Non-immune pregnant women and those immunocompromised are at highest risk. Arterial ischemic stroke associated with childhood chickenpox is a significant risk. Varicella pneumonia is the most common cause of fatality in adults (10% to 30%), and in those requiring mechanical ventilation, this may reach 50%.

In pregnant women, antibodies produced as a result of immunization or previous infection are transferred via the placenta to the fetus. Varicella infection in pregnant women could spread via the placenta and infect the fetus. If infection occurs during the first 28 weeks of pregnancy, congenital varicella syndrome may develop. Effects on the fetus can include underdeveloped toes and fingers, structural eye damage, neurological disorder, and anal and bladder malformation.

If maternal infection occurs seven days before delivery and up to eight days following birth, the baby may develop neonatal varicella with presentation ranging from mild rash to disseminated infection. Newborns who develop symptoms are at a high risk of pneumonia and other serious complications.

Maternal herpes zoster, on the other hand, constitutes little risk of neonatal complications or congenital varicella syndrome probably because of established circulating maternal antibodies.

Enhancing Healthcare Team Outcomes

Chickenpox is usually acquired after inhalation of aerosolized droplets from an infected individual. the majority of cases occurring in children less than 10. the key to lowering the morbidity of chicken pox is via education. Besides the primary caregiver, the nurse practitioner and pharmacist play a vital role in patient education. The parents of infected children should be told to trim the child's finger nails to avoid or minimize skin damage and the associated bacterial infections. Further, parents should be told not to give aspirin to young children to control fever, because of the risk of developing Reye syndrome. Finally, the parents should be told to apply cold compresses and keep the skin moisturized to pevent the itching and dryness.[15][16][17] (Level V)

Outcomes

For most children who develop chickenpox, the outcome is excellent. However, in immunocompromised individuals, there is increased morbidity and mortality. [18][19][20](Level V)


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Varicella Zoster (Chickenpox) - Questions

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What medication should not be given to pediatric patients who have chickenpox?



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When is a patient with varicella zoster lesions considered noninfectious?



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Which of the following is not a manifestation of intrauterine varicella zoster infection?



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In an adult patient with varicella, what systemic sequela is most likely to occur?



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Which of the following conditions has the risk of malignant chickenpox?



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A 4-year-old child was seen in the outpatient clinic because of a low-grade fever and a rash that started two days ago. The itchy rash initially started on the head and spread to the trunk. The lesions were initially papules, then became vesicular, and finally pustular. Lesions at all three stages are seen. What is the most probable diagnosis?

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An immunocompromised patient says, "I have been exposed to the shingles. Is there anything I can do to avoid infection?" Which of the following is the best response?



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A 4-year old girl, whom you have followed in your practice since birth, was recently exposed to chickenpox. What is appropriate management?



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Within what time period after being exposed to the virus should an immunocompromised child receive varicella immune globulin?



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Which of the following types of exposure to herpes zoster (shingles) are not an indication for varicella-zoster immune globulin in susceptible people at higher risk for developing severe varicella?



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A healthy term infant is born to a mother who develops varicella 4 days after delivery. What is the best explanation or action?



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Which disease is most associated with enanthems?



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An adult school bus driver presents with a one-week history of a pruritic, vesicular rash and a recent development of dyspnea and coughing. Physical exam finds new and old skin lesions, and a chest x-ray confirms a nodular infiltrate. Which is the most probable causative organism?



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A 65-year-old school bus driver presents with a one-week history of a pruritic, vesicular rash, dyspnea, and a cough. An exam reveals a vesicular rash with new and old lesions. A chest x-ray shows a nodular infiltrate. Which is the most probable causative organism?



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Which of the following causes chickenpox?



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A 14-year-old boy comes to the emergency department with complaints of fever 100 F, sore throat, cough, pain in the abdomen, and rash which started at the head. The rash appeared two days after the onset of fever. The patient is diagnosed with varicella infection. What should be the best treatment for varicella in this case scenario?



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Which is the most probable causative organism in a school bus driver presenting with a one week history of a pruritic, vesicular rash and has recently developed dyspnea and coughing? He has new and old lesions and a nodular infiltrate on chest x-ray.



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In a patient with chickenpox, when is there risk of contagion?



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A 3-year-old is hospitalized for pneumonia, dehydration, and hypoxemia. She requires oxygen and has little oral intake. The patient develops vesicles on the scalp and abdomen and was exposed to varicella. Her parents had refused varicella vaccine at health maintenance. What should be done?



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When is chickenpox contagious?

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Which of the following criteria do not provide evidence of immunity to varicella?



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Which of the following methods is not an acceptable method of post-exposure prophylaxis against varicella?



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Select the best test to diagnose varicella zoster virus meningitis.



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Limb hypoplasia most commonly is associated with which of the following congenital infections?



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Which of the following describes a presentation of herpes zoster (shingles)?



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Which of the following is helpful in reducing the intensity and abbreviating the course of a varicella eruption less than 72 hours old?



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When is varicella considered to be non-contagious?



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What should be given to adults diagnosed with varicella?



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What should be done for a pregnant woman exposed to chickenpox who never has had a varicella antibody test?



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Which of the following is the best management for a 1-day-old neonate exposed to chickenpox by his or her mother?



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Which is true regarding varicella (chickenpox)?



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Which of the following is the route of transmission for varicella (chickenpox)?



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What test is used to diagnose Varicella Zoster Virus Meningitis?



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What is the initial skin presentation seen in varicella (chickenpox) infection?



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A child is diagnosed with chickenpox. The parents had declined immunizations based on religious reasons. Which of the following would not be appropriate care?



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A 62-year-old male presents to the emergency department with complaints of fever, headache, rash, and chills for 3 days. A physical exam reveals vesicular eruptions along a thoracic dermatome. The rash is unilateral and does not cross the midline. He is diagnosed with shingles. What is the recommended age for shingles vaccination?



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A parent is frantic because their child has uncontrollable itching due to chickenpox. Which of the following should not be recommended?



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Varicella Zoster (Chickenpox) - References

References

Shrim A,Koren G,Yudin MH,Farine D, No. 274-Management of Varicella Infection (Chickenpox) in Pregnancy. Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC. 2018 Aug     [PubMed]
Pereira L, Congenital Viral Infection: Traversing the Uterine-Placental Interface. Annual review of virology. 2018 Jul 26     [PubMed]
Kasabwala K,Wise GJ, Varicella-zoster virus and urologic practice: a case-based review. The Canadian journal of urology. 2018 Jun     [PubMed]
Al-Turab M,Chehadeh W, Varicella infection in the Middle East: Prevalence, complications, and vaccination. Journal of research in medical sciences : the official journal of Isfahan University of Medical Sciences. 2018     [PubMed]
Rice ME,Bannerman M,Marin M,Lopez AS,Lewis MM,Stamatakis CE,Regan JJ, Maritime varicella illness and death reporting, U.S., 2010-2015. Travel medicine and infectious disease. 2018 May - Jun     [PubMed]
Schmader K, Herpes Zoster. Clinics in geriatric medicine. 2016 Aug     [PubMed]
Bakker KM,Martinez-Bakker ME,Helm B,Stevenson TJ, Digital epidemiology reveals global childhood disease seasonality and the effects of immunization. Proceedings of the National Academy of Sciences of the United States of America. 2016 Jun 14     [PubMed]
Freer G,Pistello M, Varicella-zoster virus infection: natural history, clinical manifestations, immunity and current and future vaccination strategies. The new microbiologica. 2018 Apr     [PubMed]
Dayan RR,Peleg R, Herpes zoster - typical and atypical presentations. Postgraduate medicine. 2017 Aug     [PubMed]
Inata K,Miyazaki D,Uotani R,Shimizu D,Miyake A,Shimizu Y,Inoue Y, Effectiveness of real-time PCR for diagnosis and prognosis of varicella-zoster virus keratitis. Japanese journal of ophthalmology. 2018 Jul     [PubMed]
Onyango CO,Loparev V,Lidechi S,Bhullar V,Schmid DS,Radford K,Lo MK,Rota P,Johnson BW,Munoz J,Oneko M,Burton D,Black CM,Neatherlin J,Montgomery JM,Fields B, Evaluation of a TaqMan Array Card for Detection of Central Nervous System Infections. Journal of clinical microbiology. 2017 Jul     [PubMed]
Harrington D,Haque T, Varicella Zoster Immunoglobulin G (VZIG)-Do current guidelines advocate overuse? Journal of clinical virology : the official publication of the Pan American Society for Clinical Virology. 2018 Jun     [PubMed]
Poole CL,James SH, Antiviral Therapies for Herpesviruses: Current Agents and New Directions. Clinical therapeutics. 2018 Aug 10     [PubMed]
Hayward K,Cline A,Stephens A,Street L, Management of herpes zoster (shingles) during pregnancy. Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology. 2018 Mar 22     [PubMed]
Ogunjimi B,Van den Bergh J,Meysman P,Heynderickx S,Bergs K,Jansens H,Leuridan E,Vorsters A,Goossens H,Laukens K,Cools N,Van Tendeloo V,Hens N,Van Damme P,Smits E,Beutels P, Multidisciplinary study of the secondary immune response in grandparents re-exposed to chickenpox. Scientific reports. 2017 Apr 24     [PubMed]
Ogunjimi B,Van Damme P,Beutels P, Herpes Zoster Risk Reduction through Exposure to Chickenpox Patients: A Systematic Multidisciplinary Review. PloS one. 2013     [PubMed]
Meylan P,Gerber S,Kempf W,Nadal D, [Swiss recommendations for the management of varicella-zoster virus infections]. Revue medicale suisse. 2007 Sep 19     [PubMed]
Wang X,Zhang X,Yu Z,Zhang Q,Huang D,Yu S, Long-term outcomes of varicella zoster virus infection-related myelitis in 10 immunocompetent patients. Journal of neuroimmunology. 2018 Aug 15     [PubMed]
McRae JE,Quinn HE,Macartney K, Paediatric Active Enhanced Disease Surveillance (PAEDS) annual report 2015: Prospective hospital-based surveillance for serious paediatric conditions. Communicable diseases intelligence quarterly report. 2017 Sep 1     [PubMed]
Dommasch ED,Joyce CJ,Mostaghimi A, Trends in Nationwide Herpes Zoster Emergency Department Utilization From 2006 to 2013. JAMA dermatology. 2017 Sep 1     [PubMed]

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