Fever with vesicular skin rash. Varicella

1. Fever with a Vesicular Skin Rash
Diagnosis and Differential Diagnosis
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God speaking to Prophet Muhammad (PBUH)
This (the Quran) is a clear statement for all the mankind,
and a guidance for those who are conscious of Allah (the pious
persons who love Allah and abstain from His disobedience)
Al Quran surah Al-Imran 2:138
Al- Quran

3. Fever with a Skin Rash
• Rash – widespread areas of altered skin
• Macule – an area of skin that is altered in color
• Papule – elevated solid palpable lesion < 1 cm
• Vesicle – fluid-filled lesion < 1 cm
• Purpura – bleeding into skin

4. Maculopapular Skin Rash
with or without Fever
Viral Infections
• Measles
• Rubella
• Roseola infantum
• Fifth disease
• Dengue fever
• Entero viruses
• Infectious
mononucleosis (EB virus)
Other causes
• Bacterial infections
• Scarlet fever
• Staphylococcal scalded
skin syndrome
• Immune-mediated
• Allergic Rash
• Drug Rash
• Erythema multiforme

5. Papular or Vesicular Skin Rash
with or without fever
Viral infections
• Varicella
• Herpes simplex / zoster
• Hand-foot-mouth
disease
• Molluscum contagiosum
• Small pox (eradicated)
Others
• Impetigo
• Scabies

6. Purpuric Skin Rash
with or without fever
Infections
• Meningococcal infection
• Infective endocarditis
• DIC
Blood / Vascular disorders
• ITP - thrombocytopenia
• Hemophilia
• Acute leukemia
• HSP
• Vasculitis

7. Varicella
Epidemiology, Etiology
Clinical Features, Complications, Management
Prognosis and Prevention
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

8. Case scenario
• A 4 year old child is brought to your clinic with complaint
of spots on the skin with itching for the last three day.
• On examination, child has a temperature of F.
• Rash with papular and vesicular lesions is seen most
marked on the trunk
1. What is the most likely diagnosis ?
2. Differential diagnosis ?

9. Varicella (Chickenpox)
A contagious disease
with a characteristic skin rash
(papular, vesicular and crusted lesions)
caused by Varicella - Zoster virus

10. Varicella Zoster virus
• DNA virus – Herpes group of viruses
• Primary infection results in varicella (chickenpox)
• Re-activation of infection results in herpes zoster
(shingles)
• Virus has short survival in environment

11. Varicella – Epidemiology and Transmission
• Usual age = 1 to 15 years (can occur in adults)
• DROPLET INFECTION - Human to human transmission
• INCUBATION PERIOD: 10 – 21 days
• Infectivity Period:
2 days before to 5 days after onset of rash
(till all lesions are crusted)

12. Clinical Features

13. Clinical Features
• Severity of disease is variable
• Disease is more severe as adolescents and adults
• Fever – low in mild and high in severe disease
• Papular rash starts early in disease which rapidly turns
vesicular and becomes crusted in 3 – 5 days
• Rash appears in successive crops for 3 – 5 days
• Itching of skin lesions is frequent
• Fever and rash usually subside in a week

14. Varicella (mild) – Papular-vesicular Rash

15. Varicella (severe) – Crusted Rash

16. Varicella (severe) – resulting in skin scars

17. Differential Diagnosis

18. Chicken pox vs Smallpox
Chicken pox scars Smallpox scars

19. Varicella – differentiate from scabies
• Scabies – itchy skin papules more at umbilicus, axilla
groin and palms and soles. Secondary bacterial infection
of skin may occur in infants and children

20. Complications of Varicella

21. COMPLICATIONS
• Secondary bacterial infection of skin
• Varicella Pneumonia
• Varicella Encephalitis
• Herpes Zoster (shingles)
• Congenital Varicella Syndrome
(Varicella in pregnant mother can cause Fetal infection)

22. Varicella – Severe disease with Chickenpox Encephalitis

23. Herpes Zoster
• Seen years after varicella infection
• Re-activation of dormant Varicella virus in dorsal root
ganglia of spinal sensory nerves which spreads to skin
• Appearance of vesicular rash in dermatome distribution
which remains for 2 – 4 weeks
• Causes painful neuralgia

24. Herpes Zoster
(vesicular lesion on thorax in dermatome distribution)

25. Management

26. TREATMENT - supportive
• Antipyretics for fever
• Antihistamines for itching
• Local soothing applications (Calamine lotion)
• Antibiotics for secondary bacterial infection

27. TREATMENT - specific
• Antiviral drug ACYCLOVIR
• Should be started early in disease
• Shortens duration of illness
• Reduces risk of complications

28. Prevention

29. Varicella Vaccine
• Composition – Live attenuated Varicella virus
• Efficacy – 95 % (Range, 65%-100%)
• Duration of Immunity – more than 7 years
• Schedule - 2 Dose
• First dose – at 12 -15 months of age
• Second dose – 3 months after first dose

30. Vaccination is Protection