Chicken Pox and Herpes Zosterfinal

Chicken Pox and Herpes Zoster
Megha Thapa(4060)
Meryl Shakya(4061)
Introduction : Chicken Pox (Varicella)
• Acute and highly infectious disease

caused by varicella-zoster virus.
• Characterized by a vesicular rash that
may be accompanied by fever and malaise.
• Worldwide in distribution and occurs in both
epidemic and endemic forms.
• In the absence of a vaccination programme,
affects nearly every person by mid-adulthood.
Introduction: Herpes Zoster(Shingles)
• Herpes Zoster (Shingles) is an acute viral infection also caused by Varicella Zoster virus( VZV)
• It is caused by reactivation of VZV that has remained dormant in the sensory nerve root ganglion
after the patient’s initial exposure in the form of Varicella (Chicken Pox)
• Clinically it is characterised by appearance of painful vesicular eruptions in the affected
dermatome.
Global Scenario
• Global annual incidence- 4.2 million hospitalizations

• Deaths- 4200
• Case fatality rate was about 3 per lakh cases in pre vaccination era, in developed countries
• The CDC’s new report from the ‘National Centre for Immunization and Respiratory Diseases’ shows that
deaths have dropped by as much as 88% over the first 12 years in all age groups and by 97% in young people
(20 and under), since the varicella vaccine was introduced
• Severity of disease is more among infants, pregnant women, immunocompromised and aged people (esp.
>50 yrs.)
National Scenario
National Scenario
Epidemiological Determinants: Chicken Pox
• Agent factors
• Host factors
• Environmental factors
Agent factors:
• Agent- Human alpha herpes virus 3 ( ds DNA,

enveloped)
• Primary infection causes chickenpox
• Source of infection- Case of chickenpox
through oropharyngeal secretions and lesions of
skin and mucosa
• Infectivity- 1 to 2 days before and 4 to 5 days after
rash (crust is not infective)
• Secondary attack rate- up to 90% in household
contact as it is highly contagious
Host factors:
• At least 90% of the population has had chickenpox by age 15, and 95% by young
adulthood
• Age- children <10 yrs. (severe in adults), 50% cases in 5-9 years children
• 5-10% of population are susceptible to the disease in adulthood
• Immunity- primary attack gives lifelong immunity (IgG protects against new
virus, and CMI helps in recovery from V-Z infections and prevents reactivation of
of latent infection), maternal antibody protects the infant in first few months of
life
• Second attack is rare
• Pregnancy- risk for fetus leading to congenital varicella syndrome, occuring in
0.4-2.0% of children born to mothers infected with VZV during the first 20 weeks
of gestation
Environmental factors:
• Seasonal trend, i.e. late winter to early spring in temperate regions

• In the coolest and driest months in tropics
• Periodic large outbreaks occur with an inter-epidemic cycle of 2-5 years
• Crowded area
• Heat labile virus, so outside the host cell, VZV survives in the external
environment for only a few hours, occasionally for a day or two, and is readily
inactivated by lipid solvents, detergents and proteases
Epidemiological Determinants: Herpes Zoster
• The causative agent is Varicella-Zoster Virus.
• Primary infection from VZV is followed by establishment of latent infection in cranial nerve
sensory ganglia and spinal dorsal root ganglia.
• Reactivation occurs when the immune system fails to contain latent VZV replication
• It can affect all age groups but adult population is most commonly affected.
• Only 1/3rd as contagious as primary varicella
• Chickenpox may be contracted from a case of Shingles but not vice-versa.
Transmission of virus
• VZV is highly transmissible via droplet infection and droplet nuclei

• direct contact with characteristic skin lesions of the infected person, face to face contact
• Portal of entry- upper respiratory tract or conjunctiva
• VZV can cross the placental barrier, causing congenital varicella
• Incubation period: 14- 17 days ( range 10-21 days)
Clinical Symptoms: Chicken Pox
Clinical features: Chicken pox
Varies from mild illness with only a few scattered lesions to a severe
febrile illness with widespread rash.
1. Pre- eruptive stage

• Sudden onset with mild or moderate fever, back pain, shivering and
malaise
• 24 hours in children, 2-3 days in adults(more severe)
2. Eruptive stage
• Rash is often the first sign to appear esp in children, appearing on the
day the fever starts
• Symmetrical distribution, first appearing on trunk (most abundant),
then on face, arms and then legs (mostly flexor)
• Mucosal surfaces (buccal, pharyngeal) and axilla involved, palms and
soles not affected, with the density of the eruption diminishing
centrifugally
• Rapid evolution- advances quickly through the stages of macule, papule,
vesicle, and then scab
• ‘Dew drop on rose petal’ appearance of vesicle- superficial, unilocular,
not umbilicated, filled with clear fluid and surrounded by area of
inflammation
• Pleomorphism- different stages of rash at the same time as rash appears
in successive crops for 4-5 days in the same area
• Scab begins to form 4-7 days after rash appears
• Exacerbation of fever with each fresh crop of eruption
Dewdrop on rose petal characteristic vesicle of chickenpox
Complications: Chicken Pox
• Mild, self limiting disease with <1% mortality in uncomplicated cases
• CNS- cerebellar ataxia, encephalitis, Reye’s syndrome
• Bacterial super infection, rarely necrotizing fascitis
• Varicella pneumonia
• Others- myocarditis, bleeding disorders, corneal lesion, acute GMN, hepatitis, arthritis
• Perinatal varicella- high mortality in fetus( 5 days before and 2 days after delivery)
• Congenital varicella- uncommon, limb hypoplasia, microcephaly
Clinical Stages: Herpes Zoster
Clinical stages can be divided into 3 phases
1. Pre-eruptive phase:
• It is characterised by unusual skin sensations within the affected dermatome before the
appearance of skin lesions
2. Acute eruptive phase:
• It is marked by appearance of unilateral vesicular eruptions within the affected dermatome.
• Lesions begin as macules, then papules which turn into vesicles over a period of 3-5 days. The
vesicles rupture, release their contents, ulcerate and finally crust over and become dry.
• Almost all patients experience pain and other symptoms like malaise, myalgia, headache, vertigo,
photophobia and rarely fever.
3. Chronic phase:
• Some patients experience persistent, recurring pain lasting 30 or more days after all
lesions have crusted. This is known as Post-Herpetic Neuralgia (PHN) and is a
common complication seen in elderly population.
Thoracic dermatome are most commonly involved.

Zoster opthalmicus results if there is involvement of ophthalmic division of trigeminal
nerve. It is a debilitating condition in which vesicles appear in the cornea and may lead
to blindness.
Geniculate ganglion involvement causes Ramsay-Hunt Syndrome which is
characterised by facial palsy, ipsilateral loss of taste, buccal ulceration and rash in
external auditory canal.
Zoster opthalmicus
Ramsay-Hunt Syndrome
Diagnosis
Diagnosis is based mainly on history and clinical findings
Lab investigations may be required in certain individuals who may present with atypical signs and
symptoms.
Lab investigations
Tzanck smear:
Multinucleated giant cells with Type A
intra-nuclear inclusions are seen on
microscopic examination of a smear
prepared from scraping the base of a fresh
vesicular lesion and staining with Giemsa.
Tzanck smear confirms that the lesion is
herpetic but cannot differentiate VZV from
other herpes viruses.
Lab investigations
Other tests such as Direct Fluorescent Antibody and Polymerase chain reactions have greater
sensitivity and specificity and allow differentiation between HSV and VZV.
Serologic screening of serum for IgG antibodies to assess immunity or susceptibility to varicella in
unvaccinated persons is also available
Control and prevention: Chicken Pox
Control:
• Notification, isolation of cases for 6 days after onset of rash
• Disinfection of articles soiled by nasal and throat discharges
• Antiviral (acyclovir, valacyclovir, famcyclovir) therapy for 5 days, to be started within 24 hours
• Antipyretics (aspirin contraindicated)
• Antipruritic agents
Prevention:
1. Varicella zoster immunoglobulin (VZ- Ig)
Given within 96 hours (preferably within 72 hours), 12.5 units/kg (max. 625 units) i.m. with a
repeated dose in 3 weeks in the following conditions-
• exposure to person with chicken pox/ herpes zoster (hospital, playground, newborn <5 days
• Immune compromised without history of infection/ immunization
• Premature infant in hospital
• Pregnant women
2. Vaccine
No therapeutic value in established disease.

Live attenuated vaccine.
• All children >1 year (up to 12 years) without infection: single dose
• Monovalent vaccine can be administered following one or two dose schedule (0.5 ml each
by s.c. injection)
• Seronegative adults >12 years of age: two doses with minimum interval being 6 weeks or 3
months for children (12 months- 12 years), and 4 or 6 weeks for adolescents and adults (13
years and older)
• Combination vaccines (MMRV) from 9 months- 12 years children, with 2nd dose given 6
weeks to 3 months after the first dose, or at 4-6 years of age
• As VZ Ig binds to the varicella vaccine, the two should not be given concomitantly
Breakthrough infection:
• Longstanding immunity
• 1% of recipients develop chickenpox per year
• Breakthrough disease much milder than in unvaccinated people
• Risk of breakthrough varicella 2.5 times higher if varicella vaccine administered
<30 days following MMR
• No increased risk if given simultaneously or 30 days after MMR
3. Antiviral therapy
Recommended in people ineligible for vaccine or >96 hours after contact

• Acyclovir after 5 days of exposure
• Decreases severity of the disease
Treatment: Herpes Zoster
• Anti-viral agents
Oral acyclovir 800mg 5 times daily for 7-10 days
Famciclovir 500mg 3 times daily for 7-10 days
Valaciclovir 1g 3 times daily for 7-10 days
Use of antiviral drugs reduces the duration, extent and also the risk of PHN.
• Management of pain
Analgesics
Anti-convulsants
Neuroactive agents
Prevention: Herpes Zoster
Immunisation
Zostavax is a live attenuated virus introduced in 2006 that is given to prevent herpes zoster.
The CDC recommends the use of Zostavax in US for patients 60 years and older even to those who
have previous history of chicken pox or herpes zoster infection.
Dose: 0.65 ml subcutaneously in the deltoid region
It gives protection for 5 years.
Zostavax is not available in Nepal.

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Chicken Pox and Herpes Zoster

• Acute and highly infectious disease

• Global annual incidence- 4.2 million hospitalizations

• Agent- Human alpha herpes virus 3 ( ds DNA,

• Seasonal trend, i.e. late winter to early spring in temperate regions

• VZV is highly transmissible via droplet infection and droplet nuclei

1. Pre- eruptive stage

Thoracic dermatome are most commonly involved.

1. Varicella zoster immunoglobulin (VZ- Ig)

No therapeutic value in established disease.

Recommended in people ineligible for vaccine or >96 hours after contact

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