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PubMed1994

Relapsing chickenpox in a young man with non-Hodgkin's lymphoma.

Reinfection of previously "immune" patients with varicella-zoster virus can result in recurrent chickenpox. However, relapses of chickenpox are not well recognized. We describe a young man with lymphoma who rapidly developed multiple, discrete relapses of chickenpox each time therapy with acyclovir was stopped. His cutaneous infection eventually became unremitting, despite continuous treatment with acyclovir. No evidence ever suggested visceral dissemination of varicella. The patient died suddenly; the cause of death was not determined.

Acyclovir↗
PubMed1984

Molecular dissection of the humoral immune response to individual varicella-zoster viral proteins during chickenpox, quiescence, reinfection, and reactivation.

The sequence of antibody formation to molecularly defined varicella-zoster virus (VZV) proteins was examined during the course of chickenpox, quiescence, and subsequent VZV reactivation and reinfection. The first antibodies produced after primary VZV infection were to two virion envelope glycoproteins, gp66 and gp118 , and the nucleocapsid protein p155 . Within one to two months, antibodies to a greater array of viral proteins and glycoproteins were observed. Antibodies to the immunodominant viral proteins ( gp66 , gp118 , and p155 ) persisted for years after varicella and were, therefore, excellent markers of prior VZV infection. Subclinical VZV reinfection also was associated with transient rises in levels of the same polypeptide-specific antibodies as during primary disease. The immunoglobulin response to zoster appeared more rapidly than that to chickenpox or reinfection and was to the broadest complement of viral proteins, including the distinctive VZV polypeptide p32. These radioimmune-precipitation profiles could be subdivided into six different patterns characteristic of the following clinical states: acute- and convalescent-phase chickenpox, quiescence, acute- and convalescent-phase zoster, and postzoster quiescence.

Antibodies, Viral↗
PubMed1994

Varicella-zoster virus (VZV) reactivation is related to the low response of VZV-specific immunity after chickenpox in infancy.

To clarify the cause of herpes zoster in immunocompetent children, specific humoral and cellular immunity was determined using an ELISA and a lymphoproliferative assay, respectively, in infants < 1 year of age and children > or = 1 year of age who had chickenpox. Thirteen (59.1%) of 22 infants, 17 (81.0%) of 21 children > or = 1 year of age (P < .02), and 13 (86.7%) of 15 children > or = 2 years of age (P < .001) had positive varicella-zoster virus (VZV)-specific cellular immunity. VZV-specific antibodies in infants were significantly lower than those in children > or = 1 year old (P < .01) and > or = 2 years old (P < .001). The possibility of subclinical reactivation was demonstrated by an increase in the specific cellular or humoral immunity (or both) in all of 6 infants who had negative specific cellular immunity. The low response of specific immunity and the immunologic evidence of reactivation in infants after chickenpox provide a possible explanation for the finding that chickenpox in infancy is a risk factor for herpes zoster.

Antibody Formation↗
PubMed1998

Chickenpox ARDS in a health care worker following occupational exposure.

A case is described of chickenpox acute respiratory distress syndrome in an ambulance driver after the inter-hospital transfer of a patient known to have chickenpox pneumonia. Following this exposure, he neither avoided patient contact nor received varicella zoster immune globulin. He subsequently required 13 days of ventilatory support before making a full recovery. The case described supports the contention that health care workers should be screened by serology for immunity to chickenpox before patient contact occurs, with subsequent vaccination of those who are non-immune, when the vaccine becomes available.

Adult↗
PubMed2000

The Immunization Monitoring Program Active (IMPACT) prospective five year study of Canadian children hospitalized for chickenpox or an associated complication.

BACKGROUND: Varicella vaccine was approved for use in Canada in 1998. A major goal of universal varicella vaccine programs is to reduce severe infection and associated complications. Baseline data are essential against which to judge the effectiveness of routine childhood immunization. OBJECTIVE: To describe morbidity and mortality among children hospitalized for chickenpox. Methods. From January 1, 1991, to March 31, 1996, chickenpox admissions to 11 pediatric referral centers were actively identified. Patient and illness characteristics were compared for 3 subgroups defined by prior health: healthy; unhealthy but immunocompetent; immunocompromised. RESULTS: Of 861 cases 488 (56.7%) were healthy, 75(8.7%) were unhealthy and 298 (34.6%) were immunocompromised. The immunocompromised children differed from healthy/unhealthy cases in mean age (6.4 vs. 4.0/4.6 years, respectively, P < 0.0001); median interval from rash onset to admission (2 vs. 5/5 days, P < 0.0001); complication rate (20% vs. 90%/79%; P = 0.001); and rate of acyclovir therapy (98% vs. 24%/39%; P = 0.001). Unhealthy vs. healthy cases had a higher frequency (P < 0.01) of intensive care (13.3% vs. 4.7%), ventilation (9.3% vs. 2.0%) and death (4% vs. 0.2%). CONCLUSION: These data provide a baseline for morbidity/mortality resulting from chickenpox before varicella vaccine use in Canada.

Adolescent↗
PubMed2001

Controlled trial of acyclovir for chickenpox evaluating time of initiation and duration of therapy and viral resistance.

BACKGROUND: Chickenpox is prevalent in the US despite the availability of an effective vaccine. Acyclovir treatment is limited by concerns about efficacy if given after the first day of rash and by concerns about induction of viral resistance. OBJECTIVE: Evaluate initiation and duration of acyclovir treatment of chickenpox and its effect on viral resistance. STUDY DESIGN: Randomized, placebo-controlled, double blind trial in immunocompetent patients who were stratified by age at enrollment (children, 2 to 11 years; adolescents, > or = 12 to 18 years; adults, > or = 19 years) and duration of rash (< or = 24 h vs. >24 to 48 h). Lesions were staged, counted and cultured; temperatures and symptoms were recorded daily. INTERVENTION: Subjects presenting within 24 h of rash onset (Group A) were randomly assigned to 5 or 7 days of oral acyclovir treatment, 80 mg/kg/day up to a maximum of 3,200 mg/day in four divided doses. Subjects whose rash was >24 to 48 h old were randomized to receive 5 days of acyclovir treatment beginning on the first (Group B1) or second study day (Group B2). Matching placebos were used to ensure that subjects uniformly received 28 doses of study compound. RESULTS: Of the 177 subjects recruited Group A patients who were treated on the first day of rash had the greatest number of significantly shortened event times with 5 days of therapy being equivalent to 7 days. There also were some shorter times to events for Group B1 patients who began therapy on the second day of rash vs. Group B2 patients who started acyclovir on the third. These included: time to maximum lesion formation (adolescents, P = 0.007; children, P = 0.03); 50% healing in adolescents (P = 0.005); and residual facial lesions in adults (P = 0.047). The probability of viral shedding was significantly reduced for Group A subjects vs. Group B1 subjects (P = 0.006). Viruses shed during therapy remained susceptible to acyclovir and retained normal thymidine kinase function. CONCLUSIONS: Immunocompetent children, adolescents and adults with chickenpox displayed a gradation in their clinical responses to acyclovir that correlated with the time from onset of rash to initiation of therapy. Five days of therapy is sufficient because a 7-day course provided no additional benefit. The susceptibility to acyclovir of viruses shed during treatment did not change; however, the effect of therapy on resistance of latent virus was not assessed.

Acyclovir↗
PubMedDate not supplied

Hemolytic anemia associated with cold agglutinin during chickenpox and a review of the literature.

PURPOSE: To describe the findings and cause of anemia and jaundice in a 2-year-old boy. PATIENT AND METHODS: This boy was admitted with a hemoglobin of 7.8 g/dL, a bilirubin of 1.8 mg/dL, and increased urobilinogen. RESULTS: On the second day after admission, hemolytic anemia associated with an anti-I cold agglutinin was diagnosed, which was transient and recovered without any treatment. CONCLUSION: This is a very rare complication of chickenpox; only five cases have been previously reported and these were all characterized by anti-Pr cold agglutinin with hemolytic anemia after the onset of chickenpox. We report the first case of hemolytic anemia associated with an anti-I cold agglutinin during the incubation period of chickenpox.

Adult↗
PubMed1993

Fatal chickenpox in a patient with nephrotic syndrome.

BACKGROUND: We report our experience with two patients with adult onset of chickenpox in the setting of longstanding steroid therapy for nephrotic syndrome. Ours is a 430-bed tertiary care teaching hospital, The Wellesley Hospital, Toronto, Ontario. Both patients presented as self-referrals to the emergency department. METHODS: The clinical suspicion of chickenpox was rapidly confirmed in both cases by a Tzanck smear preparation, by viral cultures of the vesicle, serology, and skin biopsy. In both patients therapy with high dose acyclovir, 10 mg/kg q8h, intravenously, was instituted based on clinical presentation. RESULTS: Delay in clinical recognition and treatment in our first case resulted in death due to multiorgan failure (MOF). Improved awareness and rapid treatment of the second patient had a favorable outcome with no sequelae. CONCLUSIONS: Chickenpox is not only a childhood illness. Although rare in the adult population, it is associated even in the nonimmunocompromised host with increased morbidity and mortality. Steroid therapy predisposes to early dissemination and a potentially fatal outcome. Adults with immunosuppression should receive prompt systemic treatment with acyclovir.

Acyclovir↗
PubMed1994

[Clinical evaluation of aciclovir granules in the treatment of chickenpox in otherwise healthy children].

The efficacy and safety of aciclovir granules (containing 40% w/w aciclovir) were evaluated in the treatment of chickenpox in otherwise healthy children. Patients presenting with chickenpox received aciclovir granules at a dose of 20 mg/kg four times daily for five to seven days. Overall 51 children received treatment with aciclovir. A further 53 patients receiving conventional symptomatic therapy acted as a control. In the aciclovir group the overall efficacy rate was 92.2%. There were reductions in the numbers of lesions, fever, itching and the duration of symptoms. No adverse experiences were reported. Overall this formulation of aciclovir appears to be a safe and effective treatment for chickenpox in this patient population. However the need for anti-viral therapy in otherwise healthy children is still the subject of debate and it might be appropriate to identify sub-groups for whom such therapy is justified.

Acyclovir↗
PubMed1990

Acute retinal necrosis as a novel complication of chickenpox in adults.

Three patients in their 20s suffered from chickenpox while in an immunocompromised state: one in pregnancy, one during a long course of corticosteroid for severe nephrotic syndrome, and the third with repeated upper airway infection due to bronchiectasis. They developed acute retinal necrosis about three weeks after the onset of chickenpox. Since acute retinal necrosis threatens sight, this unusual complication of chickenpox in adults needs serious consideration.

Acute Disease↗
PubMed1999

Chickenpox pneumonia: case report and literature review.

The incidence of primary chickenpox infection in young adults appears to be rising in the UK and other developed countries. The infection is more severe in adults than in children and complications, including pneumonia, are more frequent. An illustrative case of severe chickenpox pneumonia in an immunocompetent, non-pregnant adult smoker is presented. The epidemiology and pathology of the disease is discussed and a review of current management in the emergency department and the intensive care unit is presented. Strategies for the prevention of chickenpox pneumonia are also discussed.

Adult↗
PubMed2003

[Severe chickenpox pneumonia].

OBJECTIVE: Retrospective study of the epidemiological, clinical, diagnostic and therapeutic data corresponding to adult patients with chickenpox pneumonia that needed admission in the Intensive Care Unit (ICU) in the last 10 years. MATERIAL AND METHODS: The diagnosis was established through clinicoradiological criteria along the chickenpox progress. Assessed parameters are underlying diseases, pregnancy, smoking habits, analytical data, progress toward adult respiratory distress syndrome (ARDS), need for mechanical ventilation, and pharmacological treatment. RESULTS: They were studied 8 patients (7 women and 1 man) with an average age of 30 years (range: 25-38). Only one of the patients showed underlying pathology (chronic B hepatitis and alcoholism), and another patient was pregnant with 24 weeks of gestation. All of them were smokers. The respiratory symptoms appeared between the second and fourth day from the onset of the exanthema. All the patients showed dyspnea and in seven of them it was associated to dry cough. The chest x-ray at the time of the admission showed in all the patients a bilateral interstitial infiltrate of basal predominance. In 7 of the 8 cases less than 150,000 platelets/mm3 were observed, in 5 patients an increase of transaminases was detected, and all the patients showed elevation of LDH. In 6 patients hypoxemia (PaO2<60 mmHg) was detected with need in 3 of them of orotracheal intubation and mechanical ventilation. These 3 patients progressed toward ARDS. All the cases studied were treated with intravenous aciclovir. None of the hospitalized patients died. CONCLUSIONS: Chickenpox pneumonia is a serious complication that can force hospitalization in the ICU. The severity of the disease can range from the observation of asymptomatic radiological alterations up to ARDS. Mortality is high, but is probably declining in recent years due to the early antiviral treatment and to the application of appropriate support measures.

Adult↗
PubMed2006

Acute childhood hemiplegia associated with chickenpox and elevated anticardiolipin antibody.

Chickenpox is a common infection of childhood. Central nervous system complications, such as cerebellar ataxia and meningoencephalitis, are estimated to occur in less than 1% of cases of chickenpox. Although transverse myelitis and hemiplegia have also, although rarely, been reported, hemiplegia associated with chickenpox and elevated anticardiolipin antibody has not been reported in the literature. We report the case of a 2.5-year-old boy who developed a right hemiplegia 3 weeks after the onset of a primary varicella infection. The serum level of anticardiolipin antibody IgG was markedly elevated. Brain magnetic resonance imaging (MRI) revealed an infarction involving the left globus pallidus, caudate nucleus, and posterior leg of the internal capsule. Laboratory studies ruled out all known causes of stroke. Neurologic signs and symptoms slowly improved with supportive treatment. Varicella infection should be considered one of the possible causes of acute ischemic strokes in children. Usually, two or more risk factors are detected in children with ischemic strokes, and we suggest that all possible causes of strokes be investigated in children with ischemic strokes.

Antibodies↗
PubMed2006

[Application of Whittle's stochastic threshold theorem to a chickenpox outbreak].

OBJECTIVE: To estimate the basic reproductive rate of a chickenpox outbreak, to apply the stochastic threshold theorem to estimate the probability of an outbreak occurrence and to identify preventive measures. METHODS: The study was carried out in a daycare center comprising 16 children, 13 susceptible, one infected and two children with acquired immunity by previous disease. A stochastic susceptible - infected - removed model was applied. The basic reproductive rate (R0) was estimated using the maximum likelihood method based on probability distribution for the total size of the epidemic and making an approach of almost complete epidemic. Based on R0, the theorem was applied to establish some preventive measures for preventing a chickenpox outbreak. RESULTS: Each initially infected subject produced three new cases of infection requiring minimum vaccination coverage of 62% to prevent the outbreak or to reduce in 62% the contact among members of the group or to increase in 170% removal of infected subjects. CONCLUSIONS: The stochastic threshold theorem allows to identifying measures that could be implemented to prevent and control chickenpox outbreaks. Although the distribution of the epidemic size showed similar probability of occurrence of large and small outbreaks in a typical bimodal pattern, it illustrates the uncertainty of epidemic process in small groups, requiring close detection of outbreaks in such groups.

Chickenpox↗
PubMed1998

Ultrasonography in the diagnosis of chickenpox-related osteomyelitis.

Osteomyelitis is a recognized but uncommon complication of chickenpox. Very little published information is available regarding imaging of this condition, particularly regarding ultrasonographic appearances. We report two cases of young children who developed osteomyelitis after chickenpox infection in whom ultrasonography proved a valuable adjunct to clinical diagnosis. In both cases sonography demonstrated a subperiosteal abscess, confirming the diagnosis. Ultrasonography precisely defined the extent of the subperiosteal collection in order to guide surgical drainage. We believe ultrasonography to be a useful method of investigation in a child with limb or joint pain after chickenpox infection.

Chickenpox↗
PubMed2001

[Disseminated intravascular coagulation in chickenpox. Report of a case in a child].

The case of a healthy and immunocompetent five-year-old boy, who developed a disseminated intravascular coagulation during chickenpox is described. Disseminated intravascular coagulation manifestations were extremely severe and included macroscopic hematuria, necrotic purpura and cerebrovascular thrombosis. The outcome in this patient was a complete recovery. Nevertheless, the possibility of a seriously complicated course of chickenpox even in low-risk children subgroups suggests that the Varicella-Zoster virus infection should not be underestimated. More accurate information about the impact of chickenpox and its complications on the population is needed, in order to provide a contribution for the debate about the costs associated with this disease and the potential benefits of both the early antiviral therapy and the vaccinal prophylaxis.

Acute Disease↗
PubMedDate not supplied

Extracorporeal membrane oxygenation for chickenpox pneumonia: a single institution's experience.

The experience of extracorporeal membrane oxygenation (ECMO) use for severe chickenpox pneumonia was reviewed. Case notes of all patients treated with ECMO for this disease between 1992 and 1997 were reviewed. Of 405 patients referred for ECMO during this period, the diagnosis was chickenpox pneumonia in 14 (3.5%); all 14 were treated with ECMO. The median age of patients was 32.5 years (range 5 to 61 years). The median duration of extracorporeal support was 164 hours (range 45 to 652). Ten of 14 patients (71%) required hemofiltration. Overall survival of patients supported with ECMO was 57% (8 of 14). Deaths were caused by sepsis (5 patients, source identified in 4) and multiorgan failure (1 patient). Pneumonia as a complication of chickenpox can rapidly become severe and life threatening. Extracorporeal respiratory support may be helpful in patients refractory to conventional ventilation.

Adult↗
PubMed2004

Tuberculosis, chickenpox and scabies outbreaks in an orphanage for children with HIV/AIDS in Jamaica.

OBJECTIVES: The aim of this study is to describe the investigation and management of outbreaks of acute tuberculosis, varicella zoster virus and scabies in a residential facility for children with HIV/AIDS. METHOD: A review of the results and management for diagnosed cases of acute TB (four between 2001 and 2002) as well as varicella zoster virus (15) and scabies (14) (concurrent in March--June 2003), in a residential facility housing 24 abandoned children with HIV/AIDS was conducted. Outbreak control methods and challenges are described The modified WHO criteria were used for TB diagnosis. The diagnoses of varicella and scabies were entirely clinical. RESULTS: Of the surviving 22 children, 12 (mean age 8 years 2 months) were female, and 10 (mean age 5 years 6 months) were male. Full immunization (primary series) was documented for 16 children, partial in one child, unknown status was documented in five children. One child had received varicella vaccine previously. Eleven (50%) children had been receiving antiretroviral triple therapy since 2002 (all in Centers for Diseases Control immunological categories 2-3). Two of the four children with tuberculosis died between 2001 and 2002; these were not on antiretroviral therapy--the 2 survivors are still on antiretroviral therapy. All staff mantoux test results were negative. Fifteen (68%) children developed chickenpox as well as three caregivers. The index case was a 13-year-old resident attending a nearby school with HIV negative children. This varicella outbreak went on to affect household members for the caregivers as well as other residential facilities nearby. Scabies affected 14 children (no caregivers); the index cases were most likely three new child residents who entered the institution in 2002 (from other homes) with histories of scabies infestation. Chickenpox and scabies dual infection occurred in seven (31%) of residents. No cases of herpes zoster, disseminated varicella infection or death because of varicella occurred Diagnosed cases of chickenpox were treated with oral acyclovir Knowledge about these disease outbreaks and their control was generally lacking. CONCLUSIONS: Improvement in immunization coverage for children and staff as well as educating staff about infectious disease outbreaks, is necessary for effective control. Appropriate screening for infection/disease for all susceptible persons is essential along with timely reporting of outbreaks/reportable diseases. There is need for increased awareness of acute opportunistic infections in children with HIV/AIDS living in close proximity.

AIDS-Related Opportunistic Infections↗