Varicella: Difference between revisions
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*Caused by [[varicella zoster virus]] causing varicella (chicken pox) and later zoster ([[Shingles]]) | *Caused by [[varicella zoster virus]] causing varicella (chicken pox) and later zoster ([[Shingles]]) | ||
*Contagious until last lesion crusts over | *Contagious until last lesion crusts over | ||
**Fluid from open vesicles contains live virus <ref name="Bode">Sara Bode; Contagious Exanthematous Diseases. ''Quick References 2022''; 10.1542/aap.ppcqr.396150</ref> | |||
*Incubation period is 10-21 days with symptoms starting around day 14 <ref name="Bode"/> | |||
== | {{Herpes viruses}} | ||
==Clinical Features== | |||
[[File:Vicki Pandit - Howrah 2014-04-06 9845.jpg|thumb|Chickenpox rash on face.]] | |||
[[File:Varicela Rash.jpg|thumbnail|Male with varicella rash: lesions in various stages of development]] | [[File:Varicela Rash.jpg|thumbnail|Male with varicella rash: lesions in various stages of development]] | ||
[[File:Chickenpox blister.jpg|thumbnail|Classic blister during early stage of lesion development]] | [[File:Chickenpox blister.jpg|thumbnail|Classic blister during early stage of lesion development]] | ||
*Pruritic generalized vesicular exanthem | *[[pruritus|Pruritic]] generalized vesicular exanthem with mild systemic manifestations | ||
*Usually affects children <10y | *Usually affects children <10y | ||
===[[Rash]]=== | |||
* | *Starts on trunk or scalp as pruritic, red macules, spreads to extremities | ||
**Palms/soles spared | *Within 24hr rash becomes vesicular (on erythematous base) | ||
**Often referred to as "dew drop on a rose petal" <ref name="Bode"/> | |||
*Palms/soles spared | |||
*Lesions in various stages of development | |||
*The number of lesions can vary; usually 300 or less but can be more than 2,000 <ref name="Bode"/> | |||
===Complications=== | |||
*Can include [[encephalitis]], [[otitis media]], [[pneumonia]], [[hepatitis]], [[strep]]/[[staph]] [[cellulitis|superinfection]] of ruptured vesicles | |||
*Perinatal infection in neonates may develop serious illness | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Peds Rash DDX}} | {{Peds Rash DDX}} | ||
{{Bullous rashes DDX}} | |||
{{VZV types}} | |||
==Evaluation== | |||
*Typically made on clinical features | |||
==Management== | |||
===Supportive Care=== | |||
*[[Tylenol]], [[antihistamine]], oatmeal baths | |||
*Avoid aspirin in young children due to the risk of [[Reye syndrome]] | |||
===Antivirals=== | |||
*Routine use of antiretrovirals for uncomplicated cases in immunocompetent children is not recommended <ref>Arvin AM: Antiviral therapy for varicella and herpes zoster. Semin Pediatr Infect Dis 2002; 13:12.</ref> | |||
*However, evidence shows decreased days of fever and number of lesions<ref>Klassen TP, et al. Acyclovir for treating varicella in otherwise healthy children and adolescents. Cochrane Database Syst Rev. 2005; (4):CD002980.</ref> | |||
AAP recommends antiviral treatment (within 24hrs) for patients at risk of increased illness severity: | |||
*Any patient older than 12 years of age | |||
*Patients with chronic cutaneous or pulmonary disorders | |||
*Patients receiving long-term salicylate therapy | |||
*Patients receiving short, intermittent, or aerosolized courses of corticosteroids | |||
Other cases to consider [[acyclovir]] | |||
*Also consider in <ref>Drugs for non-HIV viral infections. Treat Guidel Med Lett. 2007; 5(59):59-70.</ref>: | |||
*Pregnancy<ref name="cdc">CDC Chicken pox acyclovir treatment [http://www.cdc.gov/chickenpox/hcp/persons-risk.html#acyclovir]</ref> | |||
====Immunocompetent Adult==== | |||
*[[Acyclovir]] 800mg PO q6hrs daily x 5 days '''OR''' | |||
*[[Valacyclovir]] 1000mg PO q8hrs daily x 14 days '''OR''' | |||
*[[Famiciclovir]] 500mg PO q8hrs x 14 days | |||
====Immunocompromised Adult==== | |||
*[[Acyclovir]] 10mg/kg IV q8hrs x 7 days | |||
====At risk children <12yo child based on AAP criteria==== | |||
*[[Acyclovir]] 20mg/kg PO q6hrs daily x 5 days | |||
*[[Acyclovir]] 10mg/kg IV q8hrs daily x 7 days | |||
====VZIG==== | |||
*Initiate VZIG alongside acyclovir for inpatient treatment of child or adult | |||
*For immunocompromised child with exposure, give as post-exposure prophylaxis if<ref>CDC. MMWR - updated recommendations for use of VariZIG - United States, 2013. July 19, 2013 / 62(28);574-576.</ref>: | |||
**Within 10 days window of exposure | |||
**VZIG given IM as 125 IU/10 kg of body weight | |||
***Up to max of 625 IU | |||
***Minimum dose 62.5 IU for patients weighing ≤ 2.0 kg | |||
***Minimum dose 125 IU for weight 2.1 - 10.0 kg | |||
*VZIG may prolong incubation period ≥1 week | |||
**Must have patient closely follow up for signs and symptoms for 28 days after exposure | |||
**If signs or symptoms of varicella occur, antiviral therapy must be started immediately | |||
==Disposition== | |||
*Most often discharge | |||
*Secondary bacterial infection most common cause of hospitalization in kids | |||
*Pneumonia most common cause of hospitalization in adults<ref>Reynolds MA, Watson BM, Plott-Adams KK, et al. Epidemiology of varicella hospitalizations in the United States, 1995-2005. J Infect Dis. 2008;197 Suppl 2:S120-S126. doi:10.1086/522146</ref> | |||
== | ==Vaccine== | ||
* | *Introduced in 2006. Prior to introduction, incidence prior to adolescence approached 90% in US | ||
* | *Vaccine is 85% effective against all disease, 90% effective against severe disease (greater than 1000 lesions) | ||
* | *Typically given at age 5 in USA | ||
*Post-exposure prophylaxis: | |||
**Ideally given within 3-5 days of exposure in immunocompetent patients | |||
**If immunocompromised patient is being given VZIG, varicella vaccine should be administered ≥5 months after VariZIG administration<ref>CDC. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007;56(No. RR-4).</ref> | |||
==See Also== | ==See Also== | ||
[[Pediatric Rashes]] | *[[Pediatric Rashes]] | ||
*[[Varicella zoster virus]] | |||
==References== | |||
<references/> | |||
[[Category: | [[Category:Dermatology]] | ||
[[Category:ID]] | [[Category:ID]] | ||
[[Category: | [[Category:Pediatrics]] |
Latest revision as of 21:13, 12 July 2023
Background
- Caused by varicella zoster virus causing varicella (chicken pox) and later zoster (Shingles)
- Contagious until last lesion crusts over
- Fluid from open vesicles contains live virus [1]
- Incubation period is 10-21 days with symptoms starting around day 14 [1]
Herpes Virus Types
- HHV-1: Herpes Simplex Virus-1
- HHV-2: Herpes Simplex Virus-2
- Herpes B virus
- Varicella zoster virus
- Varicella (Chickenpox)
- Herpes zoster (Shingles)
- Herpes zoster ophthalmicus
- Herpes zoster oticus (Ramsay Hunt syndrome)
- HHV-6 (Roseola infantum)
- HHV-8 (Kaposi’s sarcoma)
- Epstein-Barr virus
- Cytomegalovirus
Clinical Features
- Pruritic generalized vesicular exanthem with mild systemic manifestations
- Usually affects children <10y
Rash
- Starts on trunk or scalp as pruritic, red macules, spreads to extremities
- Within 24hr rash becomes vesicular (on erythematous base)
- Often referred to as "dew drop on a rose petal" [1]
- Palms/soles spared
- Lesions in various stages of development
- The number of lesions can vary; usually 300 or less but can be more than 2,000 [1]
Complications
- Can include encephalitis, otitis media, pneumonia, hepatitis, strep/staph superinfection of ruptured vesicles
- Perinatal infection in neonates may develop serious illness
Differential Diagnosis
Pediatric Rash
- Atopic dermatitis
- Bed bugs
- Contact dermatitis
- Drug rash
- Erythema infectiosum (Fifth disease)
- Hand-foot-and-mouth disease
- Henoch-schonlein purpura (HSP)
- Herpangina
- Herpes simplex virus (HSV)
- Infectious mononucleosis
- Meningitis
- Measles
- Molluscum contagiosum
- Roseola infantum
- Rubella (German measles)
- Scabies
- Scarlet fever
- Smallpox
- Varicella (Chickenpox)
Vesiculobullous rashes
Febrile
- Diffuse distribution
- Varicella (chickenpox)
- Smallpox
- Monkeypox
- Disseminated gonococcal disease
- DIC
- Purpural fulminans
- Localized distribution
Afebrile
- Diffuse distribution
- Bullous pemphigoid
- Drug-Induced bullous disorders
- Pemphigus vulgaris
- Phytophotodermatitis
- Erythema multiforme major
- Bullous impetigo
- Localized distribution
- Contact dermatitis
- Herpes zoster (shingles)
- Dyshidrotic eczema
- Burn
- Dermatitis herpetiformis
- Erythema multiforme minor
- Poison Oak, Ivy, Sumac dermatitis
- Bullosis diabeticorum
- Bullous impetigo
- Folliculitis
Varicella zoster virus
- Varicella (Chickenpox)
- Herpes zoster (Shingles)
- Herpes zoster ophthalmicus
- Herpes zoster oticus (Ramsay Hunt syndrome)
Evaluation
- Typically made on clinical features
Management
Supportive Care
- Tylenol, antihistamine, oatmeal baths
- Avoid aspirin in young children due to the risk of Reye syndrome
Antivirals
- Routine use of antiretrovirals for uncomplicated cases in immunocompetent children is not recommended [2]
- However, evidence shows decreased days of fever and number of lesions[3]
AAP recommends antiviral treatment (within 24hrs) for patients at risk of increased illness severity:
- Any patient older than 12 years of age
- Patients with chronic cutaneous or pulmonary disorders
- Patients receiving long-term salicylate therapy
- Patients receiving short, intermittent, or aerosolized courses of corticosteroids
Other cases to consider acyclovir
Immunocompetent Adult
- Acyclovir 800mg PO q6hrs daily x 5 days OR
- Valacyclovir 1000mg PO q8hrs daily x 14 days OR
- Famiciclovir 500mg PO q8hrs x 14 days
Immunocompromised Adult
- Acyclovir 10mg/kg IV q8hrs x 7 days
At risk children <12yo child based on AAP criteria
VZIG
- Initiate VZIG alongside acyclovir for inpatient treatment of child or adult
- For immunocompromised child with exposure, give as post-exposure prophylaxis if[6]:
- Within 10 days window of exposure
- VZIG given IM as 125 IU/10 kg of body weight
- Up to max of 625 IU
- Minimum dose 62.5 IU for patients weighing ≤ 2.0 kg
- Minimum dose 125 IU for weight 2.1 - 10.0 kg
- VZIG may prolong incubation period ≥1 week
- Must have patient closely follow up for signs and symptoms for 28 days after exposure
- If signs or symptoms of varicella occur, antiviral therapy must be started immediately
Disposition
- Most often discharge
- Secondary bacterial infection most common cause of hospitalization in kids
- Pneumonia most common cause of hospitalization in adults[7]
Vaccine
- Introduced in 2006. Prior to introduction, incidence prior to adolescence approached 90% in US
- Vaccine is 85% effective against all disease, 90% effective against severe disease (greater than 1000 lesions)
- Typically given at age 5 in USA
- Post-exposure prophylaxis:
- Ideally given within 3-5 days of exposure in immunocompetent patients
- If immunocompromised patient is being given VZIG, varicella vaccine should be administered ≥5 months after VariZIG administration[8]
See Also
References
- ↑ 1.0 1.1 1.2 1.3 Sara Bode; Contagious Exanthematous Diseases. Quick References 2022; 10.1542/aap.ppcqr.396150
- ↑ Arvin AM: Antiviral therapy for varicella and herpes zoster. Semin Pediatr Infect Dis 2002; 13:12.
- ↑ Klassen TP, et al. Acyclovir for treating varicella in otherwise healthy children and adolescents. Cochrane Database Syst Rev. 2005; (4):CD002980.
- ↑ Drugs for non-HIV viral infections. Treat Guidel Med Lett. 2007; 5(59):59-70.
- ↑ CDC Chicken pox acyclovir treatment [1]
- ↑ CDC. MMWR - updated recommendations for use of VariZIG - United States, 2013. July 19, 2013 / 62(28);574-576.
- ↑ Reynolds MA, Watson BM, Plott-Adams KK, et al. Epidemiology of varicella hospitalizations in the United States, 1995-2005. J Infect Dis. 2008;197 Suppl 2:S120-S126. doi:10.1086/522146
- ↑ CDC. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007;56(No. RR-4).