Mortality review vzv
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  • 1. Pathophysiology & Immune Classical Pathogen presentation responseComplications Management Vaccinations
  • 2. Chicken-pox• Member of Herpesviridae• Sharing structural characteristics as a lipid envelope surrounding a nuscleocapsid with icosahendral symmetry – total diameter 180- 200nm• Centrally located DNA 125000 bp in length• little genetic variation
  • 3. • Reservoir – human, no animal reservoir• Highly contageous – attack rate ~90% in seronegative individuals• Both sexes and all races – equivalent• Dermo & neutrotropic• Disease in children – well tolerated• More severe in adult, pregnant women and immunocompromised  often have hemorrhagic base
  • 4. • Transmission – direct contact with the rash – Airborne respiratory droplets – vertical transmission mother to baby during pregnancyLocalize replication Seeding to at undefined site Ultimately develop reticuloendothelial (presumably the viremia system nasopharynx)
  • 5. HSV• Mechanism of reactivation VZV resulting in Herpes zoster is unknown• Presumedly virus infect dorsal roots ganglia during chicken pox, remain latent until activated• Histopathologic examination  Hemorrhage, edema and lymphomcytic infiltration
  • 6. Signs and symptoms• In healthy children – the disease is generally mild• The illness usually 14–16 days after exposure – Incubation period 10-21 days• Prodromal symptoms : particularly in older children – Low-grade fever preceding skin manifestations by 1-2 D – 24-48 hr before rash • Mild abdominal pain • Mild cough and runny nose – Mild headache – malaise or irritability
  • 7. Signs and symptoms• red, itchy rash appear first on the scalp, face, trunk• quickly turn into clear fluid-filled vesicles• 24-48 hr later, clouding and umbilication of lesions• initial lesions are crusting, new crops form on trunk and then the extremities• Characteristics : various stages of evolution• oropharyngeal, vagina involvement : common• cornial involvement and serious ocular disease : rare• the average number of varicella lesion is about 300 lesions – <10 to >1,500 lesions• Itching may range from mild to intense
  • 8. • Diffuse and scattered nature of skin lesion• Vesicle involve cornium and dermis,• degenerative changes balloning, presence of multinucleated giant cells and eosinophilic intranuclear inclusion• Infection at localize blood vessels of the skin resulting in necrosis an epidermal hemorrhage• Vesicular fluid become cloudy – recruitment of PNM leucocytes and presence of degenerated cells and debris.• Ultimately vesicle may rupture and release fluid (infectious virus) or reabsorbed
  • 9. Immune response• Natural infection induces lifelong immunity• Newborn babies of immune mothers are protected by passively acquired antibodies during their first months of life• Temporary protection of non-immune individuals can be obtained by injection of varicella-zoster immune globulin within 3 days of exposure• The immunity acquired in the course of varicella prevents neither the establishment of a latent VZV infection, nor the possibility of subsequent reactivation as zoster
  • 10. High-risk groups• High risks of complications – Newborns and infants whose mothers never had chickenpox or the vaccine – Teenagers – Adults – Pregnant women – People whose immune systems are impaired by another disease or condition – People who are taking steroid medications for another disease or condition, such as asthma – People with the skin inflammation eczema• special consideration in Adults – not received the vaccine – not already had chickenpox – higher risk for exposure/transmission
  • 11. Treatment• Treatment approaches – supportive measures eg Hydration – antiviral therapy – varicella zoster immune globulin (VZIG)( 5g/day x 5days) – management of secondary bacterial infection. – Recognize underlying co-morbid eg: DKA• Early recognition of secondary bacterial infections. Failure to recognize occult infection may result in serious illness and even death.• Some case report review suggest steroid pulse therapy in severe conditoin ( IV methyprednisolone 1000mg/day x 3 days)
  • 12. Acyclovir therapy• Oral 800mg 5 times /day for 5-7days• Recommended for adolecents and adults < 24 hrs of infection• More effective in HZV infection – accelerated healing of lesions, resolution of Zoster associated pain• In Severe Chickenpox infection, should be treated at the onset  reduce occurrence of visceral complications
  • 13. • Penetration into CSF  Excellent ~ 50% of serum level• Complications: – Increase urea and increase creatinine ~5% – Thrombocytopenia ~ 6% – Gastrointestinal ~ 7% – Neurotoxicity ~ 1%
  • 14. Varicella Vaccine• Live attenuated vaccine (Oka)• Recommended in all children > 1 yr age and seronegative adult
  • 15. Varocella Immunoglobulin• special consideration in Adults – not received the vaccine – not already had chickenpox – higher risk for exposure/transmission
  • 16. References• Harrison Principles of Internal Medicine, Vol 1, 17th Edition, 2008• Davidson’s Principles & Practice of Medicine, 20th Edition, 2006• Fulminant varicella Infection complicated with ARDS and DIVC in Immunocompetent Young Adult, Soshoku et al, 2004• Varicella pneumonia in adults, A.H. Mohsen*, M. McKendrick, Eur Respir J 2003; 21: 886–891• Varicella-Zoster Virus Infection Associated with Acute Liver Failure, Hilde et al, 1998