Signs and Symptoms
- Varicella causes a spectrum of disease
- Classic childhood illness:
- Usually affects children ages 1-9
- Low-grade fever (100-103°F), headache, malaise, usually precedes rash by 1-2 d
- Pruritus, anorexia, and listlessness
- 10-21-d incubation period
- Infectious from 48 hr before vesicle formation until all vesicles are crusted, typically 3-7 d after onset of rash
- Classic exanthem:
- Lesions begin on the face, spreading to the trunk and extremities
- Papules, vesicles, or pustules, on erythematous base
- Lesions in varying stages of evolution, which is hallmark of varicella
- “Dewdrop on rose petal”
- Vesicles 2-3 mm in diameter
- Duration of vesicle formation 3-5 d
- May involve conjunctival, oropharyngeal, or vaginal mucosa
- Skin superinfection with group A streptococcus or staphylococcus in 1-4% of healthy children
- Adolescents and adults:
- Similar presentation to children but greater risk of severe disease:
- Extracutaneous manifestations in 5-50%, particularly pneumonia
- Immunocompromised patients:
- HIV, transplant patients, leukemia patients at highest risk for disseminated form
- Patients on chemotherapy, immunosuppressants, and long-term corticosteroid therapy at high risk
- More numerous lesions that may have hemorrhagic base
- Healing may take longer
- Pneumonia common in these patients
- Pregnant patients:
- Prevalent in young expectant women
- More severe disease presentation:
- Risk to fetus greatest in first half of pregnancy
- Risk to mother greatest if infection in second half of pregnancy
- Perinatal disease can occur from 5 d predelivery to 48 hr postdelivery
- Congenital varicella syndrome:
- Occasionally follows maternal zoster infection
- Musculoskeletal: Limb hypoplasia or paresis
- CNS: Microcephaly, cortical atrophy, seizures, intellectual disability
- Ocular defects: Cataracts, chorioretinitis, Horner syndrome
- Extracutaneous manifestations:
- Pneumonitis:
- 25 times more common in adults
- Highest risk in adult smokers and immunocompromised children
- Occurs 3-5 d after onset of rash
- Signs: Continued eruption of new lesions, and new-onset severe cough
- Tachypnea, dyspnea, cyanosis, pleuritic chest pain, and hemoptysis
- Cerebellar ataxia:
- May develop 5 d after rash
- Ataxia, vomiting, slurred speech, fever, vertigo, tremor
- Cerebritis:
- Develops 3-8 d after start of rash
- Duration about 2 wk
- Progressive malaise
- Headache, meningismus, vomiting, fever, delirium, seizures
- Reye syndrome risk
Geriatric Considerations |
- Increased risk of extracutaneous manifestations
- Lower immunity allows for reactivation as herpes zoster
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Pediatric Considerations |
- No aspirin for treatment of fever, possible association with Reye syndrome:
- Parents need to be cautioned regarding risk for secondary bacterial infection and possible progression to sepsis
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Pregnancy Prophylaxis |
- Pregnant women with no childhood history of varicella and no antibodies to VZV require varicella zoster immunoglobulin (VZIG)
- Varicella pneumonia in pregnancy is medical emergency, associated with life-threatening respiratory compromise and death (mortality can be 10-45%)
- Likely to occur in third trimester
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History
- Thorough history:
- Fever, systemic symptoms
- Immunization history
- Immunocompetent vs. immunocompromised
Physical Exam
- Thorough physical exam:
- Characterize rash spread and extent
- Evaluate for any extracutaneous manifestations
Essential Workup
- History and physical exam are sufficient in uncomplicated cases
- Pneumonitis:
- CXR shows 2-5 mm peripheral densities, may coalesce and persist for weeks
- Reye syndrome:
- Ammonia level peaks early
- LFTs will be elevated
- PT, PTT
- Cerebritis:
- Lumbar puncture demonstrates lymphocytic pleocytosis and elevated levels of protein
Diagnostic Tests & Interpretation
Lab
- Viral culture (results in 3-5 d), polymerase chain reaction (PCR), or direct fluorescent antibody using skin scrapings from crust or base of lesion
- Serologic tests for varicella antibodies
- PCR is diagnostic method of choice, but uncomplicated patients need no labs
Imaging
Not generally indicated unless there is concern for extracutaneous manifestations
Diagnostic Procedures/Surgery
Liver biopsy definitive test for Reye syndrome
Differential Diagnosis
- Impetigo
- Disseminated herpes
- Disseminated coxsackievirus
- Measles
- Rickettsial disease
- Insect bites
- Scabies
- Erythema multiforme
- Drug eruption (especially Stevens-Johnson syndrome)
Prehospital
- Nonimmune transport personnel must avoid respiratory or physical contact with patients
- Transport personnel who have varicella or herpes zoster should not come in contact with immunocompromised or pregnant patients
Initial Stabilization/Therapy
- Airway management and resuscitate as indicated:
- Protect airway if obtunded
ED Treatment/Procedures
- Generally, acetaminophen and antipruritics are the keys to treating classic childhood illness
- Closely cropped nails and good hygiene help prevent secondary bacterial infection
- Infants/children ≤12 yr of age:
- Acyclovir:
- Recommended in children taking corticosteroids, long-term salicylate therapy, or chronic cutaneous or pulmonary diseases
- Modest benefit, reduces lesions by 25% and fever by 1 d
- Should be given within 24 hr of symptom onset
- NOT recommended in uncomplicated varicella in healthy children
- Prophylaxis with VZIG in susceptible patients:
- Immunocompromised children at high risk for complication with significant exposure
- Susceptible children in the same household as person with active chickenpox or herpes zoster
- In 2012, FDA extended period for VZIG administration to 10 d after exposure
- VZIG in short supply, difficult to obtain
- Adolescents/adults:
- Acyclovir now recommended in adults with uncomplicated varicella initiated within 24 hr to decrease progression to disseminated disease
- Symptomatic treatment with antipyretics and antipruritics
- Pregnant women:
- If exposed to varicella, no childhood history of varicella, no antibodies to VZV, need VZIG
- 80-90% immune from prior infection, need antibody testing prior to administration of VZIG
- Acyclovir or valacyclovir prophylaxis especially during second or third trimesters:
- Safe during pregnancy (category B)
- IV acyclovir for pneumonitis/other complications:
- Respiratory, neurologic, hemorrhagic rash, or continued fever >6 d
- Immunocompromised patients:
- IV acyclovir recommended, poor PO bioavailability
- PO valacyclovir better bioavailability for lower-risk immunocompromised patients
- Should be started within 24 hr of onset to maximize efficacy
- Foscarnet for acyclovir-resistant disease
- Prophylaxis with VZIG for the susceptible immunocompromised patient
- Extracutaneous:
- IV acyclovir or foscarnet if resistant
- Vaccine:
- Children:
- Routine vaccination for all susceptible children at 12 mo and older, 2 doses
- Adolescents and adults:
- Age 13 and older without history of varicella need vaccine
- 2 doses separated by 4-8 wk
- Recommended in high-risk groups:
- Health care workers
- Family member of immunocompromised person
- Susceptible women of childbearing age
- Teachers
- Military
- International travelers
- Postexposure prophylaxis:
- Susceptible patients 12 mo or older, given within 72-120 hr, with second dose at age-appropriate interval
- Will produce immunity if not infected
- Immunocompromised persons:
- Most immunocompromised persons should not be immunized
Medication
- Acyclovir:
- Uncomplicated: Adults: 800 mg PO q.i.d for 5 d; adolescents (13-18 yr old): 20 mg/kg per dose q.i.d for 7 d; peds: 20 mg/kg suspension PO q.i.d for 5 d [max 800 mg PO q.i.d])
- Immunocompromised: Adults: 10 mg/kg IV q8h infused over 1 hr, or 800 mg PO 5 times a day for 7 d. Peds: 10-12 mg/kg IV q8h infused over 1 hr, or 500 mg/m2/d IV q8h for 7-10 d
- Valacyclovir: 1 g PO t.i.d for 5-7 d
- Famciclovir: 500 mg PO t.i.d for 7 d
- Foscarnet: Adults: 90 mg/kg q12h IV over 90-120 min for 2-3 wk; peds: 40-60 mg/kg q8h over 120 min for 7-10 d; foscarnet is not FDA approved
- Hydroxyzine: Adults: 25-50 mg IM/PO q4-6h. Peds: 0.5 mg/kg q4-6h suspension (supplied as 10 and 25 mg/5 mL)
- Diphenhydramine: Adults: 25-50 mg IV/IM/PO q4h. Peds: 5 mg/kg/d elixir
- VZIG: Adults: 625 IU IM. Peds: 1 vial per 10 kg IM to a max of 5 vials [each vial contains 125 IU])
Disposition
Admission Criteria
- Patients with pneumonia require admission:
- ICU for respiratory observation or support
- Immunocompromised patients: ICU vs. ward, depending on severity of illness
- All admitted patients must be kept in isolation
Discharge Criteria
- Immunocompetent children without evidence of Reye syndrome or secondary bacterial infection
- Adults with no evidence of extracutaneous disease
Follow-up Recommendations
Patients who are discharged need close follow-up with PCP to assure resolution without complications
- AbramowiczM, ZuccottiG, PflommJM, et al., eds. Adult immunization. In: Treatment Guidelines from The Medical Letter. New Rochelle: The Medical Letter, Inc; 2014;(12):39-48.
- AlbrechtM. Treatment of varicella (chickenpox infection) . www.uptodate.com. Accessed March 30, 2017.
- American Academy of Pediatrics. Varicella-zoster virus infections. In: KimberlinDW, BradyMT, JacksonMA, et al., eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed.Elk Grove Village, IL: American Academy of Pediatrics; 2015:846-859.
- TakharSS, MoranGJ. Serious viral infections. In: TintinalliJE, StapczynskiJ, MaO, et al., eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed.New York: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.evms.idm.oclc.org/content.aspx?bookid = 1658§ionid = 109412038.
- WooT. Postexposure management of vaccine-preventable diseases . J Pediatr Health Care. 2016;30:173-182.
See Also (Topic, Algorithm, Electronic Media Element)
Herpes Zoster