Varicella

Last Updated: 2021-10-15

Author(s): -

chickenpox, waterpox; sheep flakes, chicken pox 

Non-reportable, common disease caused by varicella (VZV).

  • 98% of the >15 year-olds have undergone initial infection, but primoinfection is still possible in adulthood (varicella adultorum).
  • Appears mainly in winter and spring.
  • Incidence: approx. 50,000-75,000 / year in Switzerland

  • Mortality: approx. 0.03 / 100'000 inhabitants / year.

  • Incubation period: approx. 2 weeks.
  • Diaplacentary transferable. Congenital varicella syndrome in 1-3/1000 pregnancies, mortality: approx. 10%. Infection in the last trimester leads to a mother's mortality of 20-45%. 

Transmittance

  • Droplet or smear infection or direct contact (saliva, fluid content, cough, sneezing).

Infectiousness

  • The affected person is already in contact 1-2 days before the onset of the disease. Once all the bubbles have dried up, there is no longer any risk of infection. Despite the formation of antibodies, the virus cannot be excreted from the organism and remains latent in the sensitive ganglia of the posterior roots. Reactivation, usually due to immunosuppression (exclusion of HIV in young people) leads to herpes zoster.

  • In 95% of cases, the infection progresses with pronounced symptoms, but in children there are often no complications. Fever, lymphadenopathy, reduced AZ and pruritus are more common in adults.
  • Overall, the clinical picture is polymorphic (Heubner's starry sky, lesions appear one after the other and not at the same time). Red maculae, small erythematous papules along the entire integument become vesicles on erythematous ground. These then cloudy and become secondary pustules. After crust formation there is no longer any danger of infection.

Clinical diagnosis, if necessary:

  • PCR VZV
  • Immunofluorescence (Syva MikroTrak®)

  • Viral culture
  • On the entire integument, capillitium, palmar temporarily affected, plantar usually no infestation.
  • Conjunctives, larynx or genital mucosa are also rarely affected.

Thin blister cover, degeneration of basal cells, giant epidermal cells, herd-shaped colliquation of rete cells, inclusion bodies.

  • Impetiginization
  • Skin gangrene
  • Purpura fulminans
  • Meningitis or meningoencephalitis
  • Ataxia in cerebellitis
  • Reye syndrome (CAVE: no administration of ASS)

  • Rarely: Guillain-Barré type.

  • Varicella pneumonia (1-6 days after exanthema, often clinically and auscultatorically difficult to diagnose → X-ray chest).

  • Otherwise, involvement of eyes, ears, joints, muscles, heart, and kidneys.

  • Ictal reaction 

  • Primary: Symptomatic, possibly acyclovir. Find complications!
  • Secondary: Foscarnet, valacyclovir.

  • Bed rest.

  • If necessary paracetamol or calf compress.

  • Adequate hydration.

  • Children: primarily only topical treatment.

Topical Therapy

  • Tanning agents (e.g. Tannosynt®-Lsg.), KI: Application in the eye area or hypersensitivity e.g. to propylene glycol.

  • Drying zinc shake mixtures

Antipruritische Therapie 

Antihistamines against pruritus (e.g. Aerius®), application: 1-3x daily; Side effects: fatigue. Contra indication: Pregnancy, lactation, hypersensitivity to ingredients.

Systemic therapy (only for severe progressions, newborns, immunosuppressed, pregnant women)

Aciclovir (Zovirax®) administration: 3x 15!mg/kg bw/d intravenously or 800mg 4-5x/day per oral; Contra indication: hypersensitivity, lactation; Side effects (very frequent): headache. CAVE: In older patients there is an increased risk of reversible neurological disorders. Adjustment of dosage for reduced kidney function. Sufficient liquid supply.

Valaciclovir (e.g. Valtrex®), administration: 3 times daily 1 g p.o.for 10 days (initial infection), 5 days (recurrence). Contra indications: Hypersensitivity, lactation. Side effects (frequent): headache, nausea. CAVE: Adjustment of dosage for reduced kidney function. Check hydration condition. 

Famciclovir (e.g. Famvir®) Application: 500 mg 2x/d. In patients >50, 500mg 3x/d should be given to prevent zosterneuralgia. Independent of meals. Drug interaction: Probenecid. Contra indication: Pregnancy, lactation, hypersensitivity to famciclovir or penciclovir. CAVE: Patients at risk of dehydration, especially older patients, should pay attention to adequate hydration. Efficacy in black patients may be reduced. 

Foscarnet (Foscavir®) Application: 3 x 40 mg/kg bw/d intravenously; Contra indication: hypersensitivity, pregnancy, lactation. Side effects (very common): granulocytopenia, anorexia, hypokalemia, hypomagnesemia, hypocalcaemia, paresthesia, headache, dizziness, nausea, vomiting, diarrhea, rash, increased serum creatinine, fever, fatigue, chills, asthenia. CAVE: Adjustment of dosage for reduced kidney function. Sufficient liquid supply. 

Brivudine (Brivex® - Tbl.) application: 125 mg 1x/d for 7 days. Drug interaction: 5-fluorouracil preparations (at least 4 weeks apart). Side effects (frequent): Nausea. AI: 5-fluorouracil therapy, pregnancy, lactation, hypersensitivity to ingredients, not tested on children and adolescents. No kidney function checks necessary. 

Prophylaxis

In Switzerland, the use of chickenpox vaccination is recommended: Are affected:

  • 11-39-year-olds, unless the varicella's gone through.
  • IgG negative persons.
  • Immunocompromised individuals.

  • Patients with severe neurodermatitis.
  • Persons with contact to the above mentioned persons (family members, persons in medical professions).

  • Post-exposure prophylaxis with acyclovir in full dosage for one week, at the latest 9 days after exposure

Live varicella vaccine (Varivax® Inj. Suspension) 2 vaccinations at intervals of at least 1 month. Indication: Active immunization against varicella. Contra indication: Basic haematological diseases, immunodeficiency (e.g. tuberculosis), temperature > 38.5°C, pregnancy, lactation. Cost: A ready-to-fill syringe (0.5 ml) amounts to CHF 67.65 as of 09/2015. The costs for this are covered by the basic insurance. Contraindications: During pregnancy. With a weakened immune system. After a severe allergic reaction (about 1/Million) to the first vaccine or to Neomycin. In case of mild illness (postponement of vaccination by 1-2 weeks). Basically good compatibility. Side effects: local redness, mild fever, chickenpox-like rash.

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