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ETIOLOGICAL AGENT:
Human herpesvirus 3 (Varicella-zoster virus)
THE DISEASE:
Chickenpox is a highly contagious, acute exanthematous
disease that is most common in childhood. It is characterized by successive
crops of lesions that progress rapidly from macules and papules to vesicles,
pustules and crusts. In children, chickenpox is generally a mild disease
with few complications. When acquired by adults, however, it is often associated
with high fever, severe constitutional symptoms and pulmonary involvement.
There is a mild prodrome.
PATHOGENESIS:
Man is the only known host. The virus is spread from
person to person by droplet inhalation or direct contact. The initial site
of virus replication is unknown but subsequently there is a viremia with
subsequent skin lesions. The early papular lesions are minute vacuoles
surrounded by ballooning degeneration of epithelial cells within the prickle
cell layer of the epidermis. In a few hours edema fluid accumulates, elevating
the stratum corneum to form a clear vesicle, while multinucleated giant
cells, containing eosinophilic intranuclear inclusions, form among the
cells at the edges and base of the lesion. As the vesicles begin to dry,
they become filled with a cloudy, fibrinous fluid containing leukocytes
and desquamated epidermal cells. The final stages of lesion formation are
characterized by crusting along with regeneration of the epithelial cells.
DIAGNOSIS:
This is based on:
1. Mild prodrome (malaise and fever)
2.
Lesions that evolve from small red macules to papules, vesicles, then pustules
that crust.
The vesicles are variable in size and shape. They are filled with straw-colored
fluid and
are surrounded at the base by an intense red corona of inflammation. They
lie on, rather
than in, the skin.
3.
Distribution of lesions with a central concentration, presenting first
and in greatest
abundance on the trunk, then the neck, face and proximal extremities. Lesions
can occur
on palms, soles and mucous membranes.
4. Lesions are painless and pruritic
5. Mild fever (100°F)
6. Presence of multinucleated giant cell with nuclear inclusions
7. Serology
8.
Crops of lesions
TREATMENT:
None indicated unless case is severe, then administer
acyclovir (Zovirax).
PREVENTION:
A new improved vaccine (Varivax, Merck & Co.)
was approved in 1995. This is a live attenuated virus vaccine. A single
0.5 ml dose is given subcutaneously to children between 1-12 years of age.
Patients 13 years of age or older should be given a 0.5 ml dose subcutaneously
followed by a second 0.5 ml subcutaneous dose four-eight weeks later. The
outer aspect of the upper arm (deltoid) is the preferred site of injection.
COMPLICATIONS:
1. Reye's syndrome (fatty
liver with encephalopathy) - varicella is the antecedent event in 20%
of the cases of Reye's syndrome, a condition that has been associated with
the
administration of salicylates to children with viral disease. Reye's syndrome
begins with
vomiting and a change in sensorium after the skin lesions have healed.
This is followed by
signs of hepatic injury, hypoglycemia and extensive fatty vacuolization
of renal tubules
and liver.
2. Zoster (shingles) - peripheral neuritis
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