Clinical case presentation of a case of Chickenpox

1. Case Presentation on
Chickenpox
Presentation By-
Dr. Sohan Khanna (JR2)
Guided By-
Dr. Rajeev Yadav
Dr. Manoj Gupta

2. Demographic Data
• Name- XYZ
• Age-10 yrs.
• Sex- Male
• Religion- Hindu
• Address- Shahpura, Distt.-Jaipur
• Occupation-Student

3. Chief Complaints
• Fever since last 4 days
• Headache since last 4 days
• Rash since last 2 days

4. History of Present Illness
• The patient was apparently asymptomatic 4 days back when he
presented in emergency department of J.K. Lon Hospital, Jaipur with
moderate fever associated with shivering and headache since 4 days.
• Patient also complained of rash since 2 days which was first noticed
on the trunk. The rash was also present on arms and legs.
• The patient also complains of itching over rash.

5. History of Past Illness
• Patient has no history of similar complaints in the past.
• No history of TB, asthma or any other medical illness.
• No history of any major or minor surgery in the past.
• No history of any allergy known to patients’ parents
Allergic History

6. Personal History-
Patient is non-vegetarian, his sleep pattern is normal, bladder and
bowel habits are normal.
Birth History-
• Prenatal – Uneventful
• Natal- Full term normal Vaginal Delivery, home delivery
Cried at birth immediately
Birth weight – 2800g
Birth length – Don’t know
• Postnatal - Uneventful

7. • History of Breast Feeding and Complimentary Feeding-
• Child was exclusively breast fed for 7 months
• Complimentary feeding started at 7th month
• Weaning – bananas and khichdi was given
• Growth Development-
• Child start to stand when he is around 1 year old
• Start to walk at 2 year old
• Start to speak when he is 1.5 year old
• All milestone was up to date to his age
• Immunization History-
• Immunization card is not available.
• His mother does not remember vaccination details except that OPV was given.
Last dose of which was when the patient was 5 years old.

8. Family History-
 He is the eldest son of a non consanguineous marriage between 30 years old
father and 25 year old mother.
 He has 1 younger sister who is not experiencing similar symptoms currently.
 There is no family history of congenital anomaly
• Contact History-
 There is no history of similar complaints in patients’ family and neighborhood.

9. General Physical Examination
• General Examination: Poor
• Semi-conscious and oriented to time place person
• No dehydration
• Temp.- 39.5 ºC (Febrile)
• Built – thin
• Height – 135cm
• Weight- 30kg
• Facial features are normal.
• B.P-110/72 mm of Hg
• P.R-100/min
• R.R-42/min
• O2 saturation-98% on room air
• No cyanosis, pallor, clubbing, icterus, lymphadenopathy and edema

10. Socioeconomic History
• Total members of family - 4
• The patient’s father is a shopkeeper and has studied till 12th class.
• The patient’s mother is a housewife and is uneducated.
• Child lives in a nuclear family.
• Total family income-Rs. 30,000/month
• Per capita income-Rs. 7500/person
• Lives in a pakka house with two rooms ,a separate kitchen and separate toilet and
bathroom.

11. Local Examination
• Multiple Maculopapular rash seen on Head, Face, Neck, Trunk, Arms and legs
• Scratch Marks seen near the site of rash
• Oral Cavity - Poor hygiene
• Nose: NAD
• Bilateral Ears: NAD

12. Systemic Examination
• CNS-
 Normal sensorium
 Oriented to time place and person.
 Bilateral pupils react to light
• Respiratory System:
 Air entry equal on both sides
• P/A - Soft ,non tender, umbilicus inverted and central and no signs of
organomegaly & bowel sounds heard on auscultation
• CVS- S1 S2 heard, no murmur present

13. Investigations
• Hb-13.6 g/dL
• Platelet count-1,80,000/mm3
• Advised tests –
• CBC
• RFTs
• LFTs
• Serum electrolytes
• Urea, Creatinine
• Chest X-Ray

14. Diagnosis
• Provisional- Child was provisionally diagnosed as case of Chickenpox
• Confirmatory Diagnosis- The lab diagnosis is rarely required. It can be done by-
1. Detecting VZV DNA using PCR or isolating VZV in cell culture from vesicular fluid, crusts, saliva,
cerebrospinal fluid or other specimens.
2. Direct immunofluorescence
3. Detection of VZV-specific serum lgM antibody - not the method of choice for confirming
varicella. Detection of serum lgM and PCR are of limited value for the confirmation of HZ.
4. Serologic screening of serum for lgG antibodies to assess immunity or susceptibility to varicella
in unvaccinated persons, e.g. in health-care workers.

15. Differential Diagnosis
• Smallpox
• Herpes Simplex
• Enterovirus
• Bullous Impetigo
• Drug Reactions
• Contact Dermatitis
• Insect Bites

16. Smallpox Chickenpox
1. Incubation: About 12 days (range: 7-17 days) About 15 days (range 7-21 days)
2. Prodromal/ symptoms: Severe Usually mild
3. Distribution of rash :
(a) centrifugal
(b) palms and soles frequently involved
(c) axilla usually free
(d) rash predominant on extensor surfaces and bony
prominences
(a) centripetal
(b) seldom affected
(c) axilla affected
(d) rash mostly on flexor surfaces.
4. Characteristics of the rash:
(a) deep-seated vesicles
(b) multilocular and umbilicated
(c) only one stage of rash may be seen at one time
(d) No area of inflammation is seen around the vesicles.
(a) superficial
(b) unilocular; dew-drop like appearance
(c) rash pleomorphic, i.e., different stages of the rash evident
at one given time, because rash appears in successive crops
(d) an area of inflammation is seen around the vesicles
5. Evolution of rash:
(a) evolution of rash is slow, deliberate and majestic, passing
through definite stages of macule, papule, vesicle and
pustule. (b)
(b) scabs begin to form 10-14 days after the rash appears
(a) Evolution of rash is very rapid
(b) scabs begin to form 4-7 days after the rash appears
6. Fever subsides with the appearance of rash, but may rise
again in the pustular stage (secondary rise of fever).
Temperature rises with each fresh crop of rash

17. During the first day
or two of rash, it
may be impossible,
from the rash alone
to differentiate
smallpox from
chickenpox

18. On day 3, the rash
associated with
each of the
diseases continues
to look very similar

19. • By Day 5, all of the
smallpox lesions are
at the same stage of
development
• However, patient
with chickenpox
shows different
stages of rash-
papules, vesicles,
pustules

20. • By day 7, no
formation of scabs
in smallpox lesions
• Most of chickenpox
lesions have
already formed
scabs, and some
scabs, in fact, have
already separated

21. • By day 10, smallpox
scabs have just begun
to form
• In chickenpox, most of
the scabs have fallen
off by day 10 (in
chickenpox, scabs
begin to form as early
as day 3 or 4, and fall
off by day 14)

22. Smallpox- pocks are more dense on arms and legs
than trunk
Chickenpox- pocks are more on back compared to
arms and legs

23. Herpes Simplex Enterovirus
Bullous Impetigo

24. Drug Reactions Contact Dermatitis Insect Bites

25. Management
• The patient presented to Emergency of JK Lon Hospital where he was given
the following treatment-
• Tab. PCM 15 mg/kg TDS
• Tab. Antihistaminic HS and Calamine lotion over rashes for itching
• Oral Acyclovir 10-20 mg/kg QID
• Tab. Amoxyclav 10 mg/ kg orally TDS or i.v. 25 mg/kg

26. About the Disease
• Caused by varicella-zoster (V- Z) virus
• Based on the host response, it can manifest either as chickenpox or shingles
• Chickenpox (common in children) and Shingles (common in adults)
• Worldwide distribution
• Occurs in both epidemic and endemic forms

27. Problem Statement
• Global Burden - In the pre-vaccine era in high-income developed countries, CFR
was about 3/1,00,000 cases
• Global annual chickenpox disease burden includes 4.2 million severe
complications leading to hospitalization and 4,200 deaths
• Burden in India – No. of cases = 66, 963 and No. of deaths = 50 (as per National
Health Profile, 2019)

28. Epidemiology
• Agent : V- Z virus aka "Human (alpha) herpes virus 3". Recovery from primary
infection (Chickenpox) is f/b establishment of latent infection in cranial nerves,
sensory, ganglia, and spinal dorsal root ganglia, often for decades, without clinical
manifestations. When CMI wanes with age or following immune-suppressive
therapy, the virus may reactivate, resulting in herpes zoster in about 10- 30 %
• Herpes Zoster is painful, vesicular, pustular eruption in distribution of ≥1 sensory
nerve roots. The virus can be grown in tissue culture.

29. • Source of infection: Usually a case of chickenpox. The virus occurs in the
oropharyngeal secretions and lesions of skin and mucosa. Rarely, patient with
herpes zoster. The virus can be readily isolated from the vesicular fluid during the
first 3 days of illness. Scabs are non-infective.
• Infectivity: 1-2 days before the appearance of rash, and 4 to 5 days thereafter The
virus tends to die out before the pustular stage. The patient ceases to be
infectious once the lesions have crusted.
• Secondary Attack Rate: about 90%

30. Host Factors
• (a) Age : primarily among children <10 years age. Few persons escape infection until
adulthood. The disease can be severe in normal adults.
• (b) Immunity : One attack gives durable immunity; second attacks are rare. The maternal
antibody protects the infant during the first few months of life. No age, however, is
exempt in the absence of immunity. The IgG antibodies persist for life and their presence
is correlated with protection against varicella. The CMI appears to be important in
recovery from V- Z infections and in protection against the reactivation of latent V-Z virus

31. • (c) Pregnancy : Infection during pregnancy presents a risk for the fetus leading to
congenital varicella syndrome. It occurs in 0.4-2.0 % of children born to mothers
who become infected with VZV during the first 20 weeks of gestation. Infants,
whose mothers had chickenpox during pregnancy, have a higher risk of
developing herpes zoster in the first years of life

32. Transmission
• Reservoir – Humans (Respiratory tract before symptom onset, vesicular fluid, in
nervous system after rash resolves)
• Infective Material – Oropharyngeal secretions
• Portal of Entry – URT or conjunctiva and close personal contact
• Portal of Exit – URT by droplet nuclei
• Transplacental route
• Mode of transmission – when infected person sneezes, tiny droplets are released
which are inhaled by non-immune person
• IP – 10-21 days

33. Control
• Controlling Source - notifications, isolation of cases for about 6 days after onset of rash
(till the crusts fall off) and disinfection of articles soiled by nose and throat discharges
• Period of Isolation – from 10th day to 21st day post-exposure or until 28th day if exposed
individual receives VZIG.
• Protection of Susceptible Host – Acyclovir given orally (>12 years age) or i.v (complicated
varicella, immunocompromised, recurrent zoster) within 24 hours of onset of rash.

34. Prevention
• Avoid healthy children and adults coming in contact with a case of chickenpox
• Infected child should not attend school for a week
• Wear surgical mask
• Trimming nails would prevent spread of virus
• Disinfect hands, clothes, and household surroundings
• Do not put finger in mouth or rub eyes after touching infected person

35. Pre-Exposure Vaccination
• Live attenuated varicella virus vaccine (not yet been introduced in National
Immunization Program)
• 1-12 years age : 1 dose 0.5 ml s/c
• > 12 years age : 2 doses 6-10 weeks apart
• Post-partum mothers : 1st dose - after delivery and before discharge from
hospital 2nd dose – 4-8 weeks after the 1st dose
• Women who get varicella vaccine can breastfeed

36. • Combination Vaccines (MMRV) - can be administered to children from 9 months-
12 years. If 2 doses of MMRV are used, the minimum interval between doses
should be 4 weeks. It is preferred that the 2nd dose be administered 6 weeks to 3
months after the first dose or at 4-6 years of age.
• 2 doses of vaccine are about 90% effective at preventing chickenpox for 10 years.
• Adverse reactions can occur as late as 4-6 weeks after vaccination. Tenderness
and erythema at the injection site seen in 25%, fever in 10-15%, and a localized
maculopapular or vesicular rash in 5%: a smaller percentage develops a diffuse
rash, usually with five or fewer vesicular lesions.

37. • Spread of virus from vaccinees to susceptible individuals is possible, but the risk
of such transmission even to immuno-compromised patients is small, and
disease, when it develops, is mild and treatable with acyclovir.
• Being live attenuated virus vaccine, it should not be given to
immunocompromised individuals, or pregnant women. The use of varicella
vaccine may be considered in clinically stable HIV-infected children or adults with
CD4+ T-cell levels ≥15 % including those receiving HAART (2 doses are
recommended). HIV testing is not a prerequisite for varicella vaccination.
• It is C/I in persons allergic to neomycin. It is recommended that following
vaccination, salicylates should be avoided for 6 weeks (to prevent Reye's
syndrome).

38. Post-Exposure Vaccination
• One dose within 72 hours of exposure will prevent varicella to extent of 98% and
up to 70% after 5 days
• Vaccination can be given after 72 hours because it can modify disease or provide
protection against future exposures
• VZIG is effective in reducing the severity when given 96 hours after exposure
• Dose – 125 U/kg body wt. up to 625 U/person
• Decision is based on –
(a) whether susceptible
(b) exposure is likely to result in infection
(c) risk of complications is more than general population

39. Complications of Varicella
• Secondary bacterial infection of
lesions
• Cellulitis, Lymphadenitis and
Subcutaneous Abscess
• Varicella Gangrenosa from Strep.
Pyogenes- a life threatening
infection

40. Complications of Varicella
• Bacteremia causing pneumonia, arthritis and osteomyelitis
• CNS manifestations-Encephalitis and Cerebellar ataxia
• Varicella hepatitis
• Acute thrombocytopenia, accompanied by petechiae, purpura,
hemorrhagic vesicles, hematuria and GI bleeding
• Nephritis, Nephrotic Syndrome and HUS

41. Thank You….