ZS

21 day old

Chicken pox in the neonate

Content

1. Case presentation

2. Varicella - clinical features

- differential diagnosis
- treatment
- complications
- vaccination
 D1 assessment

Call to A&E resus from A&E SpR requesting Paed support

S 21/7 old with chicken pox in respiratory distress

B 4/7 hx of varicella, with recent infection of sibling.

Unremarkable birth history.

A Oxygen via NRBM, preparing to obtain iv access and take blds

R Immediate attendance of Paeds consultant

 Assessment in A&E resus

A Self maintained, no added sounds.

B Self ventilating in air. Sats 92% A. Oxygen applied via NRBM

at 10L, sats 100%. Increased effort of breathing. Tachypnoic
>70 RR/min. Tracheal tug, recession ++. AE reduced
throughout, no wheeze/crackles.

C Crt 2-3 sec. Tachycardic 170 bpm. Mild-moderate dehydration.

Pale.

D BM 4.5. Alert & responsive. Not encephalopathic. Tone, power

and reflexes normal. Fontanelle normotensive. Temp 36.8

E Abdomen soft, no organomegally, slightly full.

Widespread varicella skin lesions.
 Immediate management in A&E resus

Oxygen to maintain O2 sats >95%

iv access
Blood cultures, FBC, CRP, U&E, VBG
iv cefotaxime & flucloxacillin
iv aciclovir
CXR
Fluid bolus 0.9% normal saline 10ml/kg
Maintenance ivf 10% dextrose + 0.18 NaCl

Admit Paeds, for incubator care in HDU, continuous sats

monitoring

VBG in A&E :
pH 7.31, pCO2 7.45, pO2 5.64, HCO3 24.2,
BE -2.0, Lactate 2.7, Glu 4.5
A&E Resus
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PMC 4/7 varicella, 1/7 reduced feeds, 4 hours of respiratory distress.

HPC Born AGH 38/40, NVD. Normal preg, scans & birth. ?IUGR in
later stages of pregnancy. No SCBU. BW 2.64 kg.
Consanguineous parents (1st cousins).

Whilst 8 months pregnant, babys nephew had chicken pox.

Mother therefore given immunoglobulin (see hadnt had
chicken pox before).

Babys one year old sister has recently had chickenpox

which resolved 5/7 ago.

Up until this evening, baby has been well. Was feeding by

breast 3 hourly, alert, no fever, wet nappies x3/d, BO x2/d
HPC Parents have been in touch with GP three times over the
phone in the last 5/7. Told providing feeding well and skin
lesions improving then no concerns.

At 1700hrs on day of admission, increased breathing rate

and not feeding. Parents phones GP. Told to take to A&E.

PMH/ FH Consanguineous parents. Babys nephew has a VSD.

Had BCG vacc at birth, nil else.
 Results

Blds Hb 15.9 CRP 24

from WCC 27.3 Na 135
A&E Neu 14.7 K 6.0
Plt 246 Urea 3.0
Cl 95

CBG pH 7.32 HCO3- 28.8 Na 140 Cl 102

After 6 hrs pO2 5.8 BE 1.4 K 4.3 Glu 4.9
pCO2 7.6 Ca 1.02
 D2

Summary of WR review D2

O2 requirement overnight upto 50%, currently 28% O2 sats 99%

RR70, HR 150-200, temp 38.3 despite antipyretic and reduced incubator
Temp, ivf 19ml/hr 10% dex + 0.18%NaCl. PU good amounts. BO normal. NBM

CBG pH 7.3, pCO2 8.2, HCO3 29.5, BE +1.1, Glu 5.2, Na 139, K4.0

O/E moderate recession, more marked on handling. Resp effort slightly

irreg. Tracheal tug & head bobbing. Decreased AE all areas esp RUZ.
Widespread fine creps. Crt 3 sec. Irritable on handling.

Plan: normal saline bolus 10ml/kg

regular CBG
NG tube, aspirate air
repeat CXR
explained to family, may deteriorate further or become tired
necessitating respiratory support +/- transfer
liase with PICU LGI
Wd 17
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 Day 2
Liaison with PICU consultant LGI:
Made aware of possible need for transfer; no further suggestions regarding Mx.
PICU team spoke to virologists, nil to add.

1430hrs D2
CBG
pH 7.27, pCO2 9.0, pO2 5.8, HCO3 30.3, BE +1.3, Glu 5.5, Na 140,
K3.6

Oxygen requirement unchanged. Repeat CXR reviewed, RUZ

consolidation improved, still extensive pneumonitis

Plan:
Needs CPAP
May need PICU for ventilation

Tolerated nasal CPAP, less tachycardic, improved tachypnoeic, crt <2 sec,
O2 100%

Consultant reviews on three further occasions with CBG sampling during

the afternoon.
 D2
CBG results day 2
time 0900 1430 1725 2000 2245

pH 7.30 7.27 7.33 7.31 7.36

pCO2 8.2 9.0 7.8 7.38 6.54

pO2 5.8 4.28 5.24

HCO3 29.5 30.3 30.3 27.8 27.6

BE +1.1 +1.3 +2.6 +0.8 +1.6

Na 139 140 141 140 140

K 4.0 3.6 4.8 4.4 4.1

Ca 1.05 1.03

Cl 102 102

Glu 5.2 5.5 4.9 4.5 3.5

CPAP
 D2
Transferred to PICU

Further liaison with PICU consultant LGI throughout the afternoon.

Decided that in view of CPAP and possible requirement for ventilation
to transfer to LGI. EMBRACE transfer arranged.

Arrived at PICU apyrexial and normal obs except RR 55 and O2 94% CPAP.
CPAP discontinued as unsettled. Flow-by 5L O2 started.

PICU plan :
Iv fluids 100 ml/kg/day (0.45% NaCl + 10% dextrose)
Start feeds EBM via NGT 2ml/hr and gradually increase if tolerating
Continue iv fluclox + aciclovir
Switch iv cefotaxime to ceforoxime
D/W microbiology mane
CBG. Leave off CPAP for time being.
Monitor BMs
 D3
Transferred from PICU day 3

Reviewed mane, no CPAP overnight. Less respiratory distress. O2 96%

with flow-by O2 5L. CBG CO2 7.7, pH 7.32.

D/W Micro consultant

Since ceforoxime has good Step & Staph coverage the fluclox can be
Stopped. Ceforoxime is preferred choice over cefotaxime.
Recommends send respiratory secretions for viral & bacterial culture.

Transferred back to AGH by EMBRACE after only one night at LGI

Aciclovir and cefuroxime iv.

Ivf and NG feed of EBM at 100ml/kg/day
Flow-by O2.
Stable
 Summary of WR review D4

O2 requirement still needing 0.2L/min, afebrile, RR 45-60, HR 140-160

Feeding 3 hourly bolus via NGT, 120ml/kg/day, on aciclovir and ceforoxime.

O/E settled, asleep, no resp distress, chest clear, CVS NAD, crt <2 sec,
Abdo NAD with 1-2cm liver, healing skin lesions

Plan: try breast feeding

continue iv meds
 Summary of WR review D5

Sats 100% on 3L O2. Some short bradycardias overnight. Now on C&G prem.
Tolerating some oral feeds. PUing. BO. Parents feel she is much better.

O/E alert and moving all limbs. Chest clear with some subcostal recession.
CVS NAD. ABDO NAD. Fontanelle normotensive. Oral thrush. Clinically
nappy rash. Skin lesions heeling well.

Plan: start oral nystatin

dactarin gel for nappy area
continue aciclovir, stop tomorrow on D5
continue iv abx to complete 7/7 course then for oral abx for 7/7
chase blood cultures (NAD)
monitor feeding, if struggling then may need to return to NGT feeds
 Summary of WR review D6

No oxygen requirement overnight. No respiratory distress. Feeding well.

Discharged on oral ceforoxime 7/7

48 hr ward access
For OPD r/v with Paed consultant in 3/52, repeat CXR
OPD
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 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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 Differential diagnosis

herpes simplex
disseminated herpes zoster
impetigo
drug related eruptions
contact dermatitis
erythema multiforme
Stevens Johnson syndrome
hand, foot and mouth disease
scabies
disseminated molluscum contagiosum

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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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 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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