CHICKENPOX/VARICELLA / HERPES ZOSTER

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TREATMENT / SYMPTOM / PREVENTION / POST EXPOSURE PROPHYLAXIS

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VARICELLA ZOSTER VIRUS AND CHICKENPOX : 

ynm dduh new delhi 64 1 VARICELLA ZOSTER VIRUS AND CHICKENPOX BY Dr Y.N MAURYA M.B.B.S, D.C.H Medical officer DDU Hospital Govt. of N.C.T New Delhi -64

HERPES VIRUSES : 

ynm dduh new delhi 64 2 HERPES VIRUSES V-Z Virus(HSV-3) is member of Herpes virus family

VARICELLA / CHICKENPOX : 

ynm dduh new delhi 64 3 VARICELLA / CHICKENPOX Affects children less than 10 yrs ,commonly 5-7 yrs. Causative agent is HSV-3. Source of infection is case of chickenpox / herpes zoster. Infectivity period is 1-2 day before appearance of rash till scabing of rashes occur. SAR is >90%. In India usually occurs in late winter and early spring. Incubation period is 7-21 days

VARICELLA / CHICKENPOX : 

ynm dduh new delhi 64 4 VARICELLA / CHICKENPOX Starts with prodromal symptom such as mild-moderate fever, malaise anorexia ,headache. Rashes appear on day one of fever. Rashes appear mainly on trunk, mucosal surfaces ( buccal , pharyngeal, vaginal ) are involved; palm soles usually spared.

VARICELLA / CHICKENPOX : 

ynm dduh new delhi 64 5 VARICELLA / CHICKENPOX

VARICELLA / CHICKENPOX : 

ynm dduh new delhi 64 6 VARICELLA / CHICKENPOX Rash progress as macule, papule, vesicle, scab and are pleomorphic. Vesicles are dew-drop like and surrounded by erythmatous area, vesicles may be up to 10 mm in size Patients have itching .

VARICELLA / CHICKENPOX : 

ynm dduh new delhi 64 7 VARICELLA / CHICKENPOX Subclinical varicella is very rare. Rashes may be haemorrhagic in immunocompromised pt (malignancy , AIDS , on chemotherapy) Neonates and infants, pt on steroid, pregnant women.

COMPLICATIONS OF VARICELLA : 

ynm dduh new delhi 64 8 COMPLICATIONS OF VARICELLA Sec. infection ( 5 % ) caused by gp A Streptococcus and Staphylococcus. Early manifestation is erythma at base of new vesicle. Infection can cause varicella gangrenosum, bacterial sepsis, pneumonia, arthritis, osteomyelitis, cellulitis & necrotising fascitis. Pneumonia more common in adult. Occurs 3-5 day into illness. Present as tachypnoea, cough, dyspnoea fever, pleuritic chest pain and hemoptysis. Pathologically it is interstitial pneumonitis

COMPLICATIONS OF VARICELLA : 

ynm dduh new delhi 64 9 COMPLICATIONS OF VARICELLA I.T.P (1-2%) one wk after onset of illness. Cerebellar ataxia (1 in 4000 ) occurs 6-21 day after onset of rash, present as gait disturbances, nystagmus, slurred speech. Subsides itself within 24-72 hrs. Encephalitis (1/50000) > in children of less than 5 yrs. Mortality is 5-25%.Present as nuchal rigidity, altered conciousness and seizure. Rarely it may occur in pre-eruptive stage

COMPLICATIONS OF VARICELLA : 

ynm dduh new delhi 64 10 COMPLICATIONS OF VARICELLA Other rare complications are. Purpura fulminans d/t consumptive coagulopathy G.B.S Transverse myelitis Optic neuritis Facial nerve palsy Hematuria and glomerulonephritis Hepatitis Reye’s syndrome

VARICELLA IN VACCINATED CHILD : 

ynm dduh new delhi 64 11 VARICELLA IN VACCINATED CHILD Varicella vaccine is effective >90% in preventing chickenpox. Varicella vaccine is effective 80% in preventing other varicella diseases i.e hepatitis, pneumonia, encephalitis. Sometimes after vaccination childs have chickenpox ( in first 42 days ), but it is mild, rash is more maculopapular, less than 50 in number and no fever. It is less contagious.

VARICELLA AND PREGNANCY : 

ynm dduh new delhi 64 12 VARICELLA AND PREGNANCY VARICELLA IN PREGNANCY Less than 30 wks More than 30 wks < 20 wks 20-30 wks Mother develop varicella 5 day before to 2 day after delivery Mother develop varicella >7 day before delivery Neonate develop varicella 7-10 d Neonate immune to varicella varicella embryopathy Neonate develop varicella Maternal Ig G crosses placenta efter 30 wks of gestation delivery<30 wk

VARICELLA AND PREGNANCY : 

ynm dduh new delhi 64 13 VARICELLA AND PREGNANCY If mother have varicella < 20 wk of preg. 25% fetuses have varicella infection. But only 0.4-2% fetuses have clinical varicella embryopathy (congenital varicella syndrome ). Infection at 6-12 wk---- maximal interruption of limb. Infection at 16-20 wks---eye and brain abnormality. Overall most common abnormality is of skin—75% nervous system---66% eye abnormality---50%

Congenital Varicella Syndrome : 

ynm dduh new delhi 64 14 Congenital Varicella Syndrome DAMAGE TO SENSORY NERVE Cicatricial skin lesion Hypopigmentation DAMAGE TO EYE Microophthalmia Cataracts Corioretinitis Optic atrophy DAMAGE TO BRAIN / ENCEPHALITIS Microcephaly Hydrocephaly Calcification Aplasia of brain DAMAGE TO CERVICAL /LUMBOSACRAL CORD Hypoplasia of an extremity Motor&sensory deficit Absent DTR Anisocoria Horner syndrome ANAL/ urinary sphinctor dysfunction

Congenital Varicella Syndrome : 

ynm dduh new delhi 64 15 Congenital Varicella Syndrome Cicatrial scalp rash & exophthalmos Right eye with corneal opacity Porencephalic cyst seen replacingcerebral Hemisphere on cranial CT

INVESTIGATIONS : 

ynm dduh new delhi 64 16 INVESTIGATIONS LAB INVESTIGATIONS HAVE NOT COSIDERED NECESSORY IN HEALTHY CHILDREN Leucopenia occurs in 1st 72 hrs followed by lymphocytosis. L.F.T is elevated in 75% cases. TZANK Smear ---poor sensitivity and specificity. IgM--- Commercially available methods are not reliable Four fold rise of IgG antibodies are confirmatory of acute infection. VZV can be identified by direct flourescence assay of cells from cut. lesions and by PCR amplification test.

Slide 17: 

ynm dduh new delhi 64 17 CHICKENPOX CHICKENPOX TREATMENT General & Symptomatic Specific Hygiene Soothing agent Calamine and oatmeal bath Itching Diphenhydramine 5mg/kg/d q 6hr Cetrizine(>2yr) 2-6yrs 2.5 mg BD or 5 mg OD,>6yrs 5-10 mg OD FEXOFENADINE >12yrs 60 mg BD or 120 mg OD VZIG Antiviral

CHICKENPOX : 

ynm dduh new delhi 64 18 CHICKENPOX VARICELLA IN PREGNANCY Less than 30 wks More than 30 wks < 20 wks 20-30 wks Mother develop varicella 5 day before to 2 day after delivery Mother develop varicella >7 day before delivery Neonate develop varicella 7-10 d Neonate immune to varicella varicella embryopathy Neonate develop varicella delivery<30 wk NO treatment NO treatment treatment treatment

Slide 19: 

ynm dduh new delhi 64 19 CHICKENPOX VARICELLA EMBRYOPATHY ---- No need of treatment. MOTHERS EXPOPSED TO CHICKENPOX VZIG--- 125 unit/ kg i.m within 48 hrs of exposure to varicella PREGNANT MOTHER HAVING CHICKENPOX - chances of varicella pneumonia are high, need Tt. Acyclovir I.V 10-12.5 mg/kg 8 hrly x 7 day This Tt. Modifies infection in fetus, is not certain. NEONATE & INFANT WITH CHICKENPOX I.V Acyclovir 10 mg/kg 8hrly x 14 day. NEONATE & INFANT EXPOSED TO CHICKENPOX. VZIG + I.V Acyclovir

CHICKENPOX : 

ynm dduh new delhi 64 20 CHICKENPOX CHICKENPOX IN >1 YR CHICKENPOX IN >1-12 YRS CHICKENPOX IN ADULT & >12yrs UNCOMPLICATED CHICKENPOX COMPLICATED CHICKENPOX COMPLICATED CHICKENPOX I.V Acyclovir 500mg/m2/day or 10 mg/kg 8hrly Infused over 1 hr for 10 days I.V Acyclovir 10-12.5 mg/kg 8hrly Infused over 1 hr for 7-10 days CHILDREN – No need of Tt. in healthy children (eczema - Tt.) ADULT- Oral acyclovir 800 mg/day 5 times a day for 5-7 day. Valacylovir 1gm t.i.d x7 day. Famcyclovir 500 mg t.i.d x7 day.

HERPES ZOSTER : 

ynm dduh new delhi 64 21 HERPES ZOSTER It is unilateral vesicular eruption within dermatome in a Pt. with H/O varicella. Pain in dermatome may precede 48-72 hr before rash. 3) Occurs due to reactivation of VZV in dorsal root ganglia. 4) Lifetime risk of zoster to indivilual with H/O VARICELLA is 10-15 %, it increases to >75% after 45 yrs of age.

HERPES ZOSTER : 

ynm dduh new delhi 64 22 HERPES ZOSTER 5) It is rare in healthy children of age less than 10 yrs. It may occur where CMI is decreased i.e malignancy, Chemotherapy, immunological disorder Infection in infancy, AIDS. When it occurs in children, it is milder And post herpetic neuralgia is less Commonly involve T3-L3

HERPES ZOSTER OTICUS(RAMSAY- HUNT SYNDROME) : 

ynm dduh new delhi 64 23 HERPES ZOSTER OTICUS(RAMSAY- HUNT SYNDROME) It is characterized by 1)Pain and vesicle in ext. auditory canal 2)Loss of taste in ant. 2/3rd of tongue 3)Ipsilateral facial palsy Geniculate ganglion of facial nerve is Involved. May present as earache 2-3 day prior to Vesicular eruption.

FACIAL NERVE : 

ynm dduh new delhi 64 24 FACIAL NERVE

FACIAL NERVE : 

ynm dduh new delhi 64 25 FACIAL NERVE Lacrimatory nucleus (lower pons) nervus intermedius geniculate ganglion greater petrosal nerve N. of pterygoid canal pterigopalatine ganglion zygomatic N. zygomaticotemporal nerve lacrimal nerve L. gland Superior salivary nucleus facial nerve chorda tympani nerve lingual nerve submandibular ganglion S.M gland Secretomotor nerve fibres are B type. Somatic motor nereve fibres are A type. Susceptibility to pressure is – A > B > C.

HERPES ZOSTER OTICUS(RAMSAY- HUNT SYNDROME) : 

ynm dduh new delhi 64 26 HERPES ZOSTER OTICUS(RAMSAY- HUNT SYNDROME) Facial palsy present as Loss of wrinkles on forehead Asymmetrical face. Unable to close eye. Bell’s phenomenon. Dribbling of saliva from angle of mouth. Epiphora. Hyperacusis. Loss of taste

HERPES ZOSTER OTICUS : 

ynm dduh new delhi 64 27 HERPES ZOSTER OTICUS HERPES ZOSTER OTICUS SUPPORTIVE PHARMACOLOGICAL Eye padding to prevent exposure keratitis Artificial tear ( methyl cellulose) Vitamin B12 AND B6 supplement. Zn supplement. Physiotherapy. Pain killer Prednisolone– ADULT 1mg/kg/day for 10 day Then gradually taper. CHILDREN-2mg/kg/day for 10 day then gradually taper. Antiviral –ADULT Acyclovir Valacyclovir, Famcylovir CHILDREN Acyclovir

HERPES ZOSTER OPHTHALMICUS : 

ynm dduh new delhi 64 28 HERPES ZOSTER OPHTHALMICUS Occurs due to reactivation of VZV . Present with facial pain , fever and malaise After 2-3 day of pain unilateral vesicular rash appear along distribution of 5th nerve. Extreme pain occur during inflammatory stage. Ophthalmic nerve involvement is more than maxillary. More in old age and immunocompromised pt.

HERPES ZOSTER OPHTHALMICUS : 

ynm dduh new delhi 64 29 HERPES ZOSTER OPHTHALMICUS HUTCHINSON’S RULE – ocular involvement is frequent if tip of nose presents vesicle ~75% (nasociliary nerve). Ocular involvement include --- follicular conjuntivitis. dendritic / epithelial / interstitial keratitis. Uveitis / scleritis / episcleritis. Choreoretinitis and ophthalmic neuropathy. Dendritic keratitis caused by VZV ---INFILTRATIVE Dendritic keratitis caused by HSV --- ULCERATIVE

Slide 30: 

ynm dduh new delhi 64 30 H-Z OPHTHALMICUS START ANTIVIRAL WITHIN 72 HRS TO REDUCE POST HERPETIC NEURALGIA Oral Acyclovir 600-800 mg 5 times / d for 7-10 day Valacylovir 1gm t.i.d x7 day. Famcyclovir 500 mg t.i.d x7 day. Systemic steroid ( oral ) prednisolone 40-60 mg decrease to taper within 10 day Uveitis / keratitis for cycloplegia Homatropine 5 % t.i.d. Cool compresses. Oral analgesic Cimetidine 300 mg q.i.d for 2 wks to reduce pain & pruritus. REFERAL TO OPHTHALMOLOGIST.

CHICKENPOX PREVENTION : 

ynm dduh new delhi 64 31 CHICKENPOX PREVENTION VARICELLA VACCINE It is line attenuated vaccine Available in two form monovalent polyvalent MMRV Recommended after 12 month of age 12 month – 12 yrs ---single dose >12 yrs --- two doses at least 4 wks apart CONTRAINDICATED WHEN CMI is decreased but can be given to --- ALL pt. who are in remmission HIV infected children with CD4 count >15%. In these pt two doses of vaccine is given 3 month apart.

CHICKENPOX PREVENTION : 

ynm dduh new delhi 64 32 CHICKENPOX PREVENTION VACCINATION FOR HERPES ZOSTER ZOSTAVAX Vaccine It is live but weakened version of varicella vaccine Given as single dose to prevent herpes zoster at >60 yrs. Administered on upper arm SUBCUT. Effectivity in preventing H-Zoster ~50% at >60 yrs. ~18% at >80 yrs. Even if it do not prevent herpes zoster, it reduces complication — post herpetic neuralgia, scaring and vision problem Side effect headache and local site reaction

CHICKENPOX PREVENTION : 

ynm dduh new delhi 64 33 CHICKENPOX PREVENTION POST-EXPOSER PROPHYLAXIS VARICELLA VACCINE if given within 3-5 day after exposure VARICELLA ZOSTER Immunoglobulin ( VariZIG ) 1) Immuno-compromised children 2) Pregnant women 3) Newborn exposed to maternal varicella 4) Infant exposed to varicella 5) Close contact b/w susceptible high risk pt. and pt. with varicella DOSE– 125 unit/kg (max 625 unit) I.M within 96 hrs of exposure Newborn whose mother develop varicella 5 day before -2 day after delivery should receive one vial of VariZIG IVIG – 400 mg/kg within 96 hrs of exposure

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