Neonatal Varicella : A Case Report

Dr Irman Permana, Sp.A1, Dr Ineu Nopita, Sp.A M.Kes1, Dr Tatan

Tandubela, Sp.A1, Metta Sari Septiany Djali2, Atikah Rahmawati 2,
Department of Pediatric Waled Hospital Cirebon1Faculty Medicine
Swadaya Gunung Jati College Cirebon2

Introduction: Varicella-zoster virus (VZV) is a double stranded encapsulated DNA virus

belonging to the Herpes virus family (human Herpes virus type 3, HHV-3).It is known to cause
chicken pox in children and shingles and post-herpetic neuralgia in adults.Chicken pox is an
extremely contagious rash seen in childhood and unimmunised adults where the virus spreads by
airborne transmission or via fomites.The incubation period from exposure to appearance of rash
varies from 10 to 23 days with an average of 14 days.The clinical course of the disease is usually
mild and selfremitting except in infants and persons over 15 years of age who tend to have severe
disease.
Case Report: We present the case of Asian female infant who was born at 38 weeks gestation in
Health Center. Born by 28 years old primipara mother at full term by normal vaginal delivery.
Mother had developed vesicular skin eruptions with severe pruritus suggestive of chicken pox
three days prior to delivery.
Discussion: Neonatal varicella is rarely encountered and treated even less.It is distinct from
congenital varicella caused due to the intrauterine infection of the foetus. Neonatal varicella on
the other hand is caused due to perinatal infection of the neonate in a very narrow window of time.
Incidence of varicella has been reported to be between 0.1 to 0.7/1000 pregnancies as around 88
to 98% of the population already has anti-VZV antibodies by 20–40 years of age.Although the
occurrence of neonatal varicella is quiet rare, up to 31% of infants with severe disease may
succumb to it.12 Hence it is very important to initiate anti-viral therapy in the neonate at the
earliest opportunity. The case reported here had a very high chance of contracting neonatal
varicella since the mother had developed chicken pox within three days before delivery.
Conclusion: We conclude from our study that most common in male fetus, commonly noticed in
the primigravida. The infection might have been contracted by the infant in utero through the
placenta or by an ascending infection or during passage through the birth canal via the
respiratory tract of the infant. It is this infection contracted in between seven days pre-delivery to
seven days post partum by the infant, that is described as neonatal varicella.

keywords: Neonatal varicella, pregnancy, congenital chickenpox

Introduction

Varicella-zoster virus (VZV) is a double stranded encapsulated DNA virus

belonging to the Herpes virus family (human Herpes virus type 3, HHV-3).It is
known to cause chicken pox in children and shingles and post-herpetic neuralgia
in adults.1Chicken pox is an extremely contagious rash seen in childhood and
unimmunised adults where the virus spreads by airborne transmission or via
fomites. The incubation period from exposure to appearance of rash varies from
10 to 23 days with an average of 14 days.The clinical course of the disease is
usually mild and selfremitting except in infants and persons over 15 years of age
who tend to have severe disease.1,2

1
 The presentation of the newborn after intrauterine infection with varicella
depends upon the time of onset of infection in the mother. Chicken pox infection
of the mother is not associated with first trimester abortions. Although, infection
during the first two trimesters, may result in congenital varicella syndrome, its
incidence is less than 1%.Congenital varicella syndrome has a poor prognosis
with a mortality rate of around 30% in the first few months of life. Varicella
embryopathy results in microcephaly with cortical atrophy and calcifications, limb
hypoplasia, cicatricial skin scars and hypo-pigmented areas and damage to the
autonomic nervous system.Although infection during the last trimester is usually
not associated with congenital varicella, the risk of disseminated varicella
infection to the neonate (neonatal varicella) is highest if the mother has developed
a varicella rash between seven days before and seven days after delivery.During
this period, passive immunity may not have been conferred to the newborn from
the mother and the infant’s cell-mediated immune response may not be enough to
prevent the viremia.2,3
The incidence of chickenpox varies between temperate and tropical climes.
In temperate climes, the disease occurs most commonly in late winter and early
spring. Prior to the introduction of childhood vaccination, by the age of 15, 90%
of individuals in temperate climes would have had a primary infection, and hence
seropositive compared to only 25–80% tropical countries. The incidence of
chickenpox is not precisely known since it is not a reportable disease. Best
estimates suggest an incidence of 2–3/1000 in the UK5 and between 1.6 and
4.6/1000 in the USA among 15–44 year old individuals during the 1990s.6 In both
of these countries, the incidence appears to be increasing which may be due to
increasing immigration of susceptible individuals. If this is the case, the rate is
expected to decrease due to uptake of vaccination programmes.3,4
The infection might have been contracted by the infant in utero through
the placenta or by an ascending infection or during passage through the birth canal
via the respiratory tract of the infant. It is this infection contracted in between
seven days pre-delivery to seven days post partum by the infant, that is described
as neonatal varicella.4

2
 Varicella pneumonia is a serious complication following chickenpox
more commonly occurring in adults but it is not so common in newborns.
Incidence of varicella pneumonia ranges between 1-8/1,000 cases of chickenpox.
First developing severe varicella pneumonia and second developing extensive
varicella with superimposed bacterial infection and sepsis.4,5

Case Report

We present the case of male baby 10 days was born by 28 years old
primipara mother at full term by normal vaginal delivery in health center. Mother
had developed vesicular skin eruptions with severe pruritus suggestive of chicken
pox three days prior to delivery.Baby cried well soon after birth and had no
dermatological lesions. His birth weight was 2.9 kg, length 49 cm and head
circumference 35cm, all of which were within normal range for a term baby.
Our patient was bought in while 4 days after having started on face. There
was shiny vesicular, unilocular eruptions surrounded by erythema were seen on
the forehead, face, trunk and limbs. His palms and soles were spared. The body
temperature was measured as 38,3 C, a heart rate of 140 beats per minute and
respiratory rate of 44 per minute. There were no apparent congenital
malformations. Based on maternal history typical of chickenpox and the nature of
rash on the baby, a diagnosis of neonatal varicella was made.
Considering that the rash appeared before the incubation period of varicella,
an intra uterine infection was strongly suspected.The baby is given a plan of anti
retroviral with acyclovir intra venous and santagesic with paracetamol mg if he
was hypertermi. The baby were put on supportive therapy.Formula feeding and
expressed breast milk feeds were given to the baby to restrict contact with the
mother till the mother’s lesions began crusting.

3
4
Discussion

Neonatal varicella is rarely encountered and treated even less.It is distinct

from congenital varicella caused due to the intrauterine infection of the foetus.
Neonatal varicella on the other hand is caused due to perinatal infection of the
neonate in a very narrow window of time. Incidence of varicella has been reported
to be between 0.1 to 0.7/1000 pregnancies as around 88 to 98% of the population
already has anti-VZV antibodies by 20–40 years of age.Although the occurrence
of neonatal varicella is quiet rare, up to 31% of infants with severe disease may
succumb to it. Hence it is very important to initiate anti retroviral therapy in the
neonate at the earliest opportunity.5,6 The case reported here had a very high
chance of contracting neonatal varicella since the mother had developed chicken
pox within three days before delivery. In view of the same, acyclovir therapy was
initiated prophylactically which was helpful in reducing both the severity and
duration of the rash in the baby. Acyclovir and its pro-drug form valacyclovir are
the drugs of choice for treatment of acute VZV infection. These drugs may be
given by oral or intra venous routes depending upon the severity of the infection. 6
Anti-varicella-zoster immunoglobulin (VZIG) is also advocated by some
researchers as the passively administered antibodies can limit the severity of
infection and risk of complications such as pneumonitis.Extra corporeal
membrane oxygenation (ECMO) may be required for neonates with severe
pneumonitis and having high mortality risk.6,7
Neonatal varicella is rarely encountered and treated even less.It is distinct
from congenital varicella caused due to the intrauterine infection of the foetus.
Neonatal varicella on the other hand is caused due to perinatal infection of the
neonate in a very narrow window of time. Incidence of varicella has been reported
to be between 0.1 to 0.7/1000 pregnancies as around 88 to 98% of the population
already has anti-VZV antibodies by 20–40 years of age.7,8
Primary varicella zoster virus infection during first two trimesters of
pregnancy may result in fetal infection in a quarter of cases, of which 12%
develop congenital varicella syndrome. Active varicella infection in mother
acquired perinatally may result in severe neonatal chickenpox associated with
complications. Neonatal chickenpox developing in first 12 days of life is

5
considered to be acquired intrauterine and that acquired later than 12 days is
considered to be acquired postnatally. In our cases the baby would have acquired
intrauterine infection. If the mother develops varicella within five days before or
two days after delivery, the baby is exposed to the secondary viremia of the
mother. The baby transplacentally acquires the virus but acquires no protective
antibodies because of insufficient time for antibodies to develop in the mother.9
Diagnosis is usually clinical, based upon history of chicken pox in mother
or any other contact. Serological methods may be used for confirmation of clinical
diagnosis. For rapid viral diagnosis, amplification of viral DNA in swabs taken
from skin lesion with polymerase chain reaction (PCR) is the method of choice.
Other samples may be liquor specimens tissue samples, and amniotic fluid for the
prenatal diagnosis of fetal infections. Where molecular biological methods are not
available, immunofluorescent VZV specific antigen staining in vesicle specimens
can be recommended.7-9
In this case intravenous acyclovir has been used in this case of neonatal
and complicated varicella infection in children because acyclovir is the drugs of
choice for treatment of acute VZV infection and antipiretics for prevent
hyperthermia. Varicella-zoster immunoglobulin (VZIG) reduces complications
and the mortality rate of varicella, but not its incidence. Administration as soon as
possible after exposure is best, but VZIG can prevent or attenuate varicella if
administered within 96 hours of contact. The expected duration of protection is
approximately three weeks. Intravenous immunoglobulin (IVIG) has been used to
prevent varicella after exposure when VZIG is not available. Clinical efficacy is
not exactly known. Without these drugs, mortality rates may be as high as 30%.
To reduce the risk of neonatal varicella date of delivery may also be postponed to
allow varicella antibodies to be passed to the baby.10

Conclusion

We conclude from our study that most common in male fetus, commonly
noticed in the primigravida. The infection might have been contracted by the
infant in utero through the placenta or by an ascending infection or during passage
through the birth canal via the respiratory tract of the infant. It is this infection

6
contracted in between seven days pre-delivery to seven days post partum by the
infant, that is described as neonatal varicella.

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