Varicella

Chickenpox is a highly infectious, acute contagious disease predominantly of

children under 10 years old, though it may occur at any age. Peak incidence Mar
May. It is characterised by fever and a rash, and is caused by varicella zoster virus
Around 90% of people who come into contact will develop the disease.
Transmission is through 1) direct person to person contact 2) airborne droplet
infection 3) through contact with infected articles such as clothing and bedding
Around 90% of adults over the age of 18 years have immunity for VZV in the UK
Reactivation of latent VZV will result in shingles which is more common in adults
In England and Wales, the incidence of chickenpox is approximately 1290
cases per 100,000 person-years

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Varicella clinical features

The incubation period is from 14 up to 21 days
chicken pox is infectious from a few days before the onset of rash develops and not more than six days after
first lesions appear
the rash begins as macular lesions which develop into papular, or vesicular lesions (filled with fluid) and later
becomes pustular
chickenpox rash has a centripetal distribution - mostly on the face and trunk and sparsely on the limbs
there is erythema around the lesions and they are intensely itchy
usually the rash peaks at around 48 hours in immunocompetent people
vesicles dry and crust over, and sometimes scar if scratched to excess oropharynx and genital tract
mucous membranes may be involved as well
new lesions can emerge for up to 5 days

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Varicella

In children under 10 years, the disease is usually mild and self limiting, but a more severe
infection can be seen in
1) adults - especially in pregnant women and in smokers since they are
at an increased risk of developing fulminanting varicella pneumonia
2) neonates
3) immunosupressed individuals there is an increased risk of developing
disseminated or haemorrhagic varicella
Signs of severe infections include:
respiratory symptoms (clinical respiratory signs are often absent).
densely cropping vesicles
haemorrhagic rash
bleeding from gums, haemoptysis, GI bleeding
any neurological changes - cerebellar signs, encephalopathy
persisting fever with new vesicles >6 days after onset
General recommendationis for school exclusion for 5 days from onset of rash

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Treatment
Treatment is usually symptomatic in milder disease paracetamol or ibuprofen can be given to
reduce flu like symptoms, fever and pain
antivirals should be considered for patients who presents within 24-48 hours of new vesicles
(indicating an evolving disease) antiviral therapy should be continued for at least 1 week

oral aciclovir may also be given to 1) immuocompetent adults and older adolescents
2) Infants 3) severe infection at any age 4) immunosuppression 5)severe cardiorespiratory
disease 6) chronic skin disorder
Varicella zoster immune globulin (VZIG) VZIG prophylaxis can be used in individuals who
complete all of the following criteria:
significant exposure to chickenpox or herpes zoster
a clinical condition that increases the risk of severe varicella, this includes immunosuppressed
patients, neonates and pregnant women
no antibodies to VZ virus
Immunosuppressed patients should be given immunoglobulin to varicella zoster and aciclovir
within two days of contact with varicella. If they develop chicken pox they should be treated with
aciclovir.
Antibiotics should be given for secondary infections

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Differential diagnosis

Differential Diagnoses
Bullous Pemphigoid
Drug Eruptions
Herpes Simplex
Impetigo
Insect Bites
Smallpox
Scabies

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VARIOLA

-Major
-Minor
acute onset of fever greater than 101 F
(38.3 C) followed by a rash characterized
by firm, deep seated vesicles or pustules in
the same stage of development without
other apparent cause.

produce characteristic
cytoplasmic inclusions, the most important
of which are known as
Guarnieri bodies

DRUGS ERUPTION

The morphologies are myriad and include

morbilliform, urticarial, papulosquamous,
pustular, and bullous. Medications can also
cause pruritus and dysesthesia without an
obvious eruption.

Bullous pemphigoid is an acute or

chronic autoimmune
skin disease, involving the formation of
blisters, more appropriately known as
bullae, at the space between the skin layers
epidermis and dermis. It is classified as a
type II hypersensitivity reaction.
Clinically, the earliest lesions may appear
urticarial
Nikolsky's sign is negative unlike
pemphigus vulgaris where it is positive.

Scabies
Scabies causes severe
itching that is usually worse at night and a
rash with tiny blisters or sores

There are four cardinal signs of scabies

Herpes Simplex

Common infection of the skin or mucosa

may affect the face and mouth (orofacial
herpes), genitalia (genital herpes)

Complications
Majority of children recover without any complications but neonates, adults,
pregnant women and those who are immunocompromised may have more
serious complications

Pulmonary involvement.5-14% of adults

CNS involvement.cerebellar ataxia and/or encephalitis
Secondary bacterial infections.inc osteomyelitis
Haemorrhagic complications..GI bleeds, DIC, cerebral bleeds
In pregnancy..significant maternal mortality and congenital VAR syndrome
Others.. arthritis, glomerulonephritis, myocarditis, and purpura fulminans

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Varicella vaccination
Varicella vaccine is a lyophilised preparation which contains live attenuated organisms
of the Oka strain of varicella zoster virus.
should be administered as deep subcutaneous injection and can be given together with
other live vaccines such as MMR
children from one year to under 13 years of age; a single dose of varicella vaccine will
give protection for around 90% of children
children aged 13 years or older and adults - should receive two doses of varicella vaccine
four to eight weeks apart, around 75% will have protection against clinical chickenpox (1)

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