Paeds - Case Presentation of Chicken Pox : A comprehensive presentation covering case study from symptomatic clinical presentation, lab study, diagnosis, therapies, disease etiology, virus reinfection, complications, etc. The setting of this case is in a General Hospital located in Peninsular Malaysia.

1. Infectious Disease
MO CME

2. Case presentation
! Name : KD
! DoA : 20/2/2014 @ 7.41pm
! DoD : 22/2/2014 @ 5.12pm

3. 1y9m Indian Girl
NKMI, 1st hospitalization
Fitting 1/7
Fever 1/7
Rashes 2/7
Reduce oral intake

4. Fitting x 1 episode
! At 6.50pm on the day of admission
! GTC of bilateral UL and LL
! Drooling of saliva
! lasted for 5minutes, aborted spontaneously
! Post ictal drowsiness for 5minutes
! Prior to that child was sleeping, and witnessed by
mother
No uprolling of eyeball/ tongue biting/ clenching of teeth
No urinary/bowel incontinence

5. Fever started 12pm on the day of adm
! High grade fever, T 38’C
! No ear/eye discharge
Noted vesicular lesion started since 1 day before fever
! Initially macular rashes then developed into papular
and vesicular lesions
! Started from the face then spread to trunk and limbs
! Itchy
Reduce oral intake
! Usually 5 oz 4-5x/day + solid food 2x/day
! Now 3 oz 3x/day and refuse solid food

6. Less active
Not irritable
No change of behaviour
No abnormal movement
No URTI/UTI Sx
No vomiting/ diarrhea
No FHx of febrile fit/ seizure
! Ill contact elder brother: Started to have chicken
pox 1 week prior

7. Other Relevant History
! Birth Hx: FT SVD BW 3.1kg, ANC/PNC uneventful
! PMHx : 1st Hospitalization. NKMI
! PSHX : NIL
! Immunisation Hx : Completed up to age. Last taken
for 18mo
! Developmental Hx : Appropriate with age
• Diet Hx: Adult diet 2x/day (1 bowl/serving) + FM 5 oz
4-5x/day

8. Physical examination
Alert, pink , Pupil Equal and reactive
Warm peripheries, CRT < 2, good PV
Hydration good
Throat : not injected, tonsils not enlarged, no ulcers seen
Ears : TM visualized, ear wax +
Lungs: Clear . Equal AE
CVS : DRNM
P/A : Soft, no liver/spleen palpable
+ Gen papular rashes and vesicular lesions with erythematous base mostly
over head and trunk, minimal over extremities and genitalia
CNS : Reflexes not brisk. Tone normal. Babinski down going.
BP 98/56mmHg, PR 126bpm, RR 26, T 38.5’C, SPO2 100%, DXT 5.8mmol/L
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9. Lab Findings
! FBC:
! Hb 13.9 g/dL
! Hct 41.5%
! PLT 263 x 10^9/L
! WBC 12.5 x 10^9/L
! Neut 73% / Lymph 17%
! RP:
! Ur 4.3 mmol/L
! Na 132 mmol/L
! K 3.4 mmol/L
! Creat 42 umol/L
! LFT:
! Total Prot 70g/L
! Alb 41 g/L
! Glo 29 g/L
! Total Bil 12.5 umol/L
! ALT 22 U/L
! ALP 286 U/L
! Ca 2.43 mmol/L
! Mg 0.86 mmol/L
! PO4 1.28 mmol/L

10. IMP: Simple Febrile Fit sec
to Varicella Zoster Infection
Mx:
! Isolation room
! IVD Half Maintenance HSD% 20ml/H
! Syr Acyclovir 180mg QID x 10/7
! Fit education

11. Z1``1 a5s2wdq
More details? CLICK HERE

12. Varicella-zoster Infection

13. http://synapse.koreamed.org/DOIx.php?id=10.3344/kjp.2013.26.3.242vmode=PUBREADER#!po=29.1667
http:// www.turbosquid.com/3d-models/varicella-zoster-virus-3d-model/493482

14. ! Distinct forms of disease
! Varicella (chickenpox) : Primary VZV infection
results in the diffuse vesicular rash.
! Herpes zoster (shingles) : Endogenous
reactivation of latent VZV typically results in a
localized skin infection

16. Transmission routes
! Airborne transmission
! Contact with aerosolized droplets from
nasopharyngeal secretions
! Direct cutaneous contact with vesicle fluid from
skin lesions

17. Pathogenesis
http://synapse.koreamed.org/DOIx.php?id=10.3344/kjp.2013.26.3.242vmode=PUBREADER#!po=29.1667

18. http://www.inmo.ie/MagazineArticle/PrintArticle/6449

19. Incubation period
! Incubation period : 8 -21 days
! Average : 14-16 days
! Infectivity : last from 48 hours prior to the
onset of rash until skin lesions have fully
crusted.
! Administration of varicella zoster immune
globulin (VZIG) following exposure can prolong
the incubation period from 21 days to 28 days.

20. Reinfection
! Second episodes of varicella infection in
immunocompetent individuals rarely occur
! Subclinical reinfection with VZV is common

21. ! Develop within fifteen days after the
exposure
! Prodrome of fever, malaise, or pharyngitis,
loss of appetite
! Development of a generalized vesicular rash
within 24 hours.

22. CROP = PRESENCE OF LESIONS IN DIFFERENT
STAGES OF DEVELOPMENT AT THE SAME TIME
! Macule, papule, pustule, vesicular rash : formation
generally stops within 4 days (250 – 500 lesions).
! 3 successive waves
! Pruritic
! Crusted papules : 6 days in normal host
! Face, trunk and extremities
! Crusts tend to fall off within about one to two weeks
! Temporary area of hypopigmentation

24. Dew drop on a pink rose
petal

26. Diagnosis
! Clinical signs and symptoms
! Tzanck smear
! Multinucleated giant cell

27. Laboratory testing
! PCR : rapid and sensitive
! Specimen from skin lesion, CSF, BAL, blood
! Direct fluorescent antibody (DFA)
! active vesicular skin lesions
! Serologic testing :
! protection against subsequent infection.

28. Complications
1. Skin/soft tissue infections
2. Neurologic complications
3. Pneumonia
4. Hepatitis

29. ! Retrospective review in paeds pt over 1year (1996) in one centre in
S’pore, Total 8 pt :
! 6/8: CNS complications ! 3 encephalitis (1 pt with status
epilepticus for 2H had behavioural prob and poor memory), 2
cerebellar ataxia, 1 aseptic meningitis.
! 1 pt p/w AGN with superimposed staphylococcus infection of skin
ulcers
! 1 pt had disseminated VZ infection with multiorgan involvement
(haemorrhagic vesicles, hepatitis, ileus with mesenteric adenitis
and disseminated intravascular coagulation) ! died after 5 days.
Complicated varicella zoster infection in 8 paediatric patients and review of literature, H.K.
Phuah, C.Y. Chong, K.W. Lim, H.K. Cheng
Singapore Med J, 39 (1998), pp. 115–120

30. THERAPY

31. THERAPY
! Symptomatic treatment
! Antihistamines : symptomatic treatment of pruritis
! Acetaminophen : treat fever
! Avoid significant excoriation and secondary
bacterial infection.

32. THERAPY
! Antiviral therapy
! Acyclovir : effective for varicella if given
during the first 24 hours of rash
! Dose :
! Children : 20 mg/kg PO qid for 5 days
! Adult : 800 mg IV qid for 5 days
! Immunocompromised host: 10 mg/kg IV q 8 hr
(up to 500 mg IV q 8 hr) for 7 days

33. ACYCLOVIR
! Large, multicenter trial: Acyclovir vs placebo: significant
reduce morbidity in child adolescents. 20mg/kg QID (max
800mg QID) for 5/7.
! When initiated 24H : One day less fever, reduce constitutional
illness score by D4 illness, more rapid cutaneous healing, fewer
skin lesions.
! American Academy of Pediatric Committee:
! High risk group for severe varicella
! If therapy can be initiated within 24 hours after onset of rash
Article: Acyclovir to Treat Varicella, IJ Frieden, West J Med. Apr 1994; 160(4): 361-362.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022430/?page=1

34. Acyclovir Duration?
! Balfour et al, 2001; Randomized, double-blind trial; Oral
Acyclovir 20mg/kg QID (max 800mg)
! Group A: 24H rash, Acyclovir x 1/52 or 5/7 Acyclovir + 2/7
placebo.
! Group B: 24-48H rash, Acyclovir 5/7 + 2/7 placebo
! Conclusion:
! No Benefit from longer seven-day medication course
! Earlier treatment demonstrated quicker cessation of new
lesion formation, reduce fever duration, rapid skin healing.
Balfour HH, et al. Controlled trial of acyclovir for chickenpox evaluating time of initiation and duration of therapy
and viral resistance. Pediatric Infect Dis J. October 2001;20:919–26.

35. IV Acyclovir Dosage?
! We describe three newborns who developed varicella six hours, five
or eight days after delivery. Because of the high lethality rate of
congenital varicella treatment with acyclovir appeared to be
indicated. Acyclovir was administered intravenously in a dosage of 3
X 5, 3 X 7.5, and 3 X 10 mg/kg/day for three to five days. All patients
showed prompt clinical improvement and the skin lesions
disappeared. Side effects were not observed. Dependent on the
dosage radioimmunological determination of acyclovir serum levels
revealed basic values between less than 0.34 to 13.9 mumol/l; peak
levels ranged from 14.0 to 70.2 mumol/l. Our preliminary results
demonstrate that acyclovir can be successfully used to treat
congenital varicella. A dosage of at least 3 X 7.5 mg/kg/day is
recommended.
Treatment of congenital varicella with acyclovir, [Article in German],
Wirth S1, Ehninger G, Baumann W. Monatsschr Kinderheilkd. 1987 Oct;135(10):
696-8.

36. Acyclovir in healthy child?
! Cochrane Database Syst Rev 2004; 3 Large RCT studies
[1966-2003] that evaluated otherwise healthy children 0 –
18yo with chickenpox
! Acyclovir was associated with a reduction in the number of
days with fever (-1.1 days, 95% CI -1.3 to -0.9) and in
reducing the maximum number of lesions (-76 lesions, -145
to -8). Results were less supportive with respect to the
number of days to no new lesions and the number of days
to the relief of itching. There were no clinically important
differences between acyclovir and placebo with respect to
complications associated with chickenpox or adverse
effects associated with the treatment.
Klassen TP, Belseck EM, Wiebe N, Hartling L. Acyclovir for treating varicella in otherwise
healthy children and adolescents. Cochrane Database Syst Rev 2004; :CD002980.

37. Intravenous
Immunoglobulin (IVIg)
! YC Huang et al, 2001; 24 newborn infants whose mother had developed a varicella
rash 15 infants whose mothers' rash appeared within 7 days before and 5 days after
delivery were categorised as an at-risk group and received IVIG prophylaxis (500
mg/kg) administered soon after birth or post-natal contact either alone or with
intravenous acyclovir (5 mg/kg every 8 h) for a total of 5 days starting from 7 days
after the onset of maternal rash. Of four infants receiving IVIG alone, two
developed clinical varicella. None of ten infants receiving both IVIG and ACV
contracted varicella. One infant receiving ACV alone had no varicella vesicles
either. Of nine infants in the not at-risk group four had undetectable varicella-zoster
virus antibody on admission and developed clinical varicella subsequently
! The combination of intravenous immunoglobulin given soon after birth and
prophylactic acyclovir intravenously administered 7 days after the onset of
maternal rash can effectively prevent perinatal varicella.
Prophylaxis of intravenous immunoglobulin and acyclovir in perinatal varicella.,
Huang YC1, Lin TY, Lin YJ, Lien RI, Chou YH., Eur J Pediatr. 2001 Feb;160(2):91-4.

38. Varicella Zoster
Immunoglobulin
! POSTEXPOSURE PROPHYLAXIS OF VARICELLA
! Provide temporary passive immunity Reduce severity ( 96H
post exposure) for high risk pt:
1. Immunocompromised children
2. Neonates whose mother had sign and symptoms of varicella
at time of delivery (5d before to 2d afer delivery)
3. Prem born 28w or BW 1kg exposed during neonatal
period.
4. Pregnant women.

39. http://farmasi.ummc.edu.my/uploadfile/formulary/
Formulary_3_2_2010(16_4_18).pdf

40. Prevention

42. Minimum Intervals Between
Doses of Varicella Vaccine
! 12 months
through 12 years
of age
! 13 years of age
or older
3 months
4 weeks
MERCK: Varivax / ProQuad / Zostavax ®

43. Varicella Vaccine
Immunogenicity and Efficacy
! Detectable antibody
! 97% of children 12 months-12 years following 1
dose
! 99% of persons 13 years and older after 2 doses
! 70%-90% effective against any varicella disease
! 95%-100% effective against severe varicella
disease

44. Varicella Breakthrough
Infection
! Immunity appears to be long-lasting for most
recipients
! Breakthrough disease much milder than in
unvaccinated persons (50 lesions, ± low fever)
! Taiwan, 2000 – 2007 : 22,640 cases / 1,057,345
(2.1%). 82.6% vaccine effectiveness.

45. Vaccine vs Acyclovir?
! Vaccinated child : 18 skin lesions (median)
! Acyclovir : 336 lesions
! Expenses of acyclovir course from pharmacy +
expenses of lost wages burdened by parents to
stay at home caring for sick child ! $$$$
! Vaccination more more cost-effective
! Emergence of acyclovir-resistant strains in
immunodef.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022430/?page=1