Download What are the complications of Varicella?

Case 4:
“Ang Pamana”
Pediatric II – Module IV
Dr. Christine Bernal
B4
Feeding
poorly
Mother –
vesiculopapular
lesions (trunk
and chest face
and extremities
Illlooking
5 days prior
delivery
Cherry
6 days old
Afebrile
Generalized
vesiculopapular
lesions
Guide Questions
1. What conditions present with vesiculopustular
eruptions?
2. What kind of Varicella infection does this infant have?
3. Differentiate the following: Neonatal Varicella,
Congenital Varicella Syndrome and Herpes Zoster?
4. What is the treatment for Varicella?
5. What are the complications of Varicella?
6. Identify the individuals who would need treatment with
either Acyclovir or VZIG?
7. How would you prevent Varicella (Primary prevention
and Postexposure prophylaxis)?
What conditions present with
vesiculopustular eruptions?
Infectious
• Viral
– Varicella-zoster virus
– Hespes simplex virus 1 and 2
– Coxsackievirus A4, A5, A7-10 A16 and B1-3, B5
– Echonovirus 4, 6, 9, 11, 17, 19, 33
– Enterovirus 7,2
• Bacterial
– S. aureus
– S. pyogenes
Non Infectious
•
•
•
•
•
•
•
Drug reaction
Stevens-Johnson syndrome
Anthropod bites
Contact dermatitis
Erythema Multiforme
Thermal Injury
Toxic epidermal necrolysis
What kind of Varicella infection
does this infant have?
Clinical Diagnosis of Varicella

Diagnostic features:
Papulovesicular eruptions associated with fever
and mild constitutional symptoms
 Rapid progression of macules to papules to
vesicles and finally to crusts
 Appearance of symptoms simultaneously in one
anatomic area
 Predominant central distribution of lesions
including the scalp
 Eventual crusting of all skin lesions

Feeding
poorly
Mother –
vesiculopapular
lesions (trunk
and chest
face and
extremities )
Illlooking
5 days prior
delivery
Cherry
6 days old
Afebrile
Generalized
vesiculopapular
lesions
Varicella-zoster infection
• Skin lesions are first seen
on the body and inner
aspects of the thighs but
spread quickly to the face,
scalp and proximal parts of
the limbs
Feeding
poorly
Mother –
vesiculopapular
lesions (trunk
and chest face
and extremities )
Illlooking
5 days prior
delivery
Cherry
6 days old
Afebrile
Generalized
vesiculopapular
lesions
Neonatal Varicella
• Infants whose mothers develop
varicella in the period from 5 days
prior to delivery to 2 days
afterward
• Infant acquires the infection
transplacentally as a result of
maternal viremia, which may
occur up to 48 hr prior to the
maternal rash
• Infant's rash may occur toward
the end of the 1st week to the
early part of the 2nd week of life
VZD Diagnosis
• Diagnosis is usually made clinically
– The presence of a herpesvirus can be
demonstrated by a Tzanck smear that
demonstrates inclusions
– Infection can be confirmed by acute and
convalescent titers of VZV antibody
Differentiate the following:
Neonatal Varicella
Congenital Varicella Syndrome
Herpes Zoster
Neonatal Varicella
• Infants whose mothers develop varicella in the
period from 5 days prior to delivery to 2 days
afterward.
• High mortality
• Transplacental, which may occur 48 hrs. prior to
the maternal rash.
• Infant rashes may occur during 1st wk or early 2nd
wk of life
• Since the mother does not develop the antibody,
the infant receives a large dose of virus without
maternal anti –VZV antibody
Neonatal Varicella
• If the mother was more than infected 5 days,
she can still pass the virus to her child, but in a
milder form due to her anti-VZV.
• Treatment:
– 1 vial of human varicella-zoster immune globulin
(VariZIG)
– Acyclovir (10mg/kg q8hrs IV) when lesions
develop
Congenital Varicella
• Infants whose mothers develop varicella early
in pregnancy.
– Gestational period. Major development and
innervation of the limb buds and maturation of
the eyes
Time of infection
Organ system involved
6-12wk of gestation
Maximal interruption of Limb development
16-20 wk of gestation Eye and Brain development
Congenital Varicella
Stigmata of Varicella-Zoster Infection
Damage to Sensory Nerves
Cicatricial skin lesions
Hypopigmentation
Damage to Optic Stalk and Lens Vesicle
Microphthalmia
Cataracts
Chorioretinitis
Optic Atropy
Damage to Brain/encephalitis
Microcephaly
Hydrocephaly
Calcifications
Aplasia of the Brain
Damage to the Cervical or Lumbosacral
cord
Hypolasia of an extremity
Motor and sensory deficits
Absent DTR
Hormer syndrome
Anal/urinary sphincter dysfuction
Congenital Varicella
• Diagnosis
– Maternal history
– PCR
– Fetal cord sampling and Chorionic villus sampling
(detection of viral DNA, virus or antibody)
Persistent positive VZV IgG antibody titer after 1218months of age is indicator of prenatal infection
in an asymptomatic child.
Congenital Varicella
• Prevention
– Vaccination of the mother of the varicella Vaccine
3 months prior to pregnancy
Herpes Zoster
• Vesicular lesions clustered within 1 or less
commonly 2 adjacent dermatomes
Elderly
Burning pain
Clusters of skin lesions in
a dermatomal pattern
Post herpetic neuralgia
(complication)
Children
Mild rash
Infrequently assoc. with localized
pain, hyperesthesia, pruritus and low
grade fever
Symptoms of acute Neuritis are
minimal
Complete resolution within 1-2 wks
Herpes Zoster
Herpes Zoster
• Inc. risk
– Acquired varicella infection in the 1st yr of life
– Mothers have varicella infection in the 3rd
trimester of pregnancy
– Immunocompromised
• Can have disseminated cutaneous disease that mimics
varicella, visceral dissemination with pnueumonia,
hepatitis, encephalitis and DIC
Herpes Zoster
• treatment
Healthy Adult Acyclovir (800mg 5x a day PO for 5 days)
Famciclovir (500mg tid PO for 7 days)
Valacyclovir(1000mg tid PO for 7 days)
Healthy children Supportive therapy
Or with oral acyclovir (20mg/kg/dose, max
800 mg/dose)
Immunocompro Acyclovir (500mg/m2 or 10mg/kg q8hr IV)
mised children
What is the treatment for
Varicella?
Treatment
• 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.
Acyclovir
• 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.
• Available as cap (200-800 mg), PO liquid (400 mg/5
mL), and parenteral injection (500 mg/mL
• Pediatric
• 80 mg/kg/d PO divided in 4-5 doses for 5 d;
not to exceed 3200 mg/d
• 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
What are the complications
of Varicella?
Complications
• Bacterial Infections
– usually caused by group A Streptococci (the most common)
and S. aureus
– range from superficial impetigo to cellulitis, lymphadenitis,
and subcutaneous abscesses
– Erythema of the base of a new vesicle
• early manifestation of secondary bacterial infection
– Recrudescence of fever
• 3–4 days after the initial exanthem
– Varicella vaccine
Complications
 Pneumonia
 The frequency of varicella pneumonia may be greater in
the parturient and may lead to premature termination of
pregnancy.
 Recognized chiefly in otherwise healthy adults and
immunocompromised children
 Severe complication
 Respiratory symptoms
○ cough, dyspnea, cyanosis, pleuritic chest pain, and hemoptysis,
usually begin within 1–6 days after the onset of the rash
 Smoking
○ a risk factor for severe pneumonia complicating varicella
Complications
• Encephalitis and Cerebellar Ataxia
– patients younger than 5 yr or older than 20 yr. – high
morbidity
– Neurologic symptoms:
• nuchal rigidity, altered consciousness, and seizures
• usually begin 2–6 days after the onset of the rash but may occur
during the incubation period or after resolution of the rash
– Cerebellar ataxia have a gradual onset of gait disturbance,
nystagmus, and slurred speech
– Clinical recovery:
• rapid, occurring within 24–72 hr, and is usually complete
– Reye syndrome of encephalopathy and hepatic
dysfunction associated with varicella
• rare; salicylates are no longer routinely used as antipyretics
Complications
• Mild thrombocytopenia
– occurs in 1–2% of children
– may be associated with transient petechiae
• Rare complications
– Purpura, hemorrhagic vesicles, hematuria, and
gastrointestinal bleeding are that may have serious
consequences.
6. Identify the individuals who
would need treatment with
either Acyclovir of VZIG.
Acyclovir
• Children with defects in cell-mediated immunity,
chronic atopic dermatitis or asthma, iatrogenic
immunosuppression or long-term systemic steroid
use, splenic dysfunction, nephrotic syndrome high
risk for varicella-related complications
• Healthy adults at increased risk of severe varicella
infections
• Immunocompromised/immunosuppressed
populations
VZIG
• Highly susceptible, VZV-exposed
immunocompromised or immunosuppressed
populations
–
–
–
–
Bone marrow transplantation
Leukemia
Congenital or acquired immunodeficiency syndromes
Undergoing immunosuppressive therapy for
transplant procedures
– Infants born to mothers who experience onset of
chickenpox five days prior to delivery or within two
days after delivery
7. How would you prevent
Varicella ( Primary prevention
and Postexposure prophylaxis)?
Primary Prevention - Varicella vaccine
• susceptible children aged 12 months to 12 years
• Live-attenuated preparation of serially propagated and
attenuated wild Oka strain
• Dose: 0.5 ml subcutaneously(recommended) or IM, one dose
for children <12 yrs or younger and 2 doses 4-8 weeks apart
for individuals older than 12 yrs of age
– 95% immunogenic for immunized healthy children
between 12 mos and 12 yrs of age with humoral and CMI
response
– 78-82% after 1 dose and 99% after 2 doses for people 13
yrs or older
– Duration of immunity: at least 11 yrs (USA); 20 yrs (Japan
studies)
Primary Prevention - VZIG
• High Risk:
– Immunocompromised, susceptible children without
history of varicella or varicella immunzation
– Normal susceptible adults, especially pregnant
women
– Newborn infant of a mother who had onset of
Chickenpox within 5 days before or 48 hours after
delivery
– Hospitalized premature infant (>28 wks gestation)
whose mother has not had chickenpox
– All hospitalized premature infants <28 wks gestation
or weighing <1,000 gms regardless of maternal
historyof varicella
Post-exposure Prophylaxis
• IV
Acyclovir
should
be
given
to
immunocompromised patients with Varicella or
Herpes zoster
• Oral acyclovir given to healthy children with
varicella within 24 hrs of the rash results in
diminution and duration of skin lesions. Should
be considered in adolescents and adults with
Varicella
• VZIG should be given within 96 hrs of exposure to
susceptible high risk patients for severe or
complicated Varicella
Thank you