[Case] Varicella infection

Nota - Ini adalah catatan kes yang ditemui ketika bekerja dalam latar klinik, semoga menjadi panduan sendiri (atau rakan sekerja) untuk masa akan datang. Catatan ini hanya bertujuan sebagai rujukan-pantas-peribadi (personal quick reference) tentang maklumat penting yang berkaitan.. Jadi untuk pembaca awam (bukan anggota kesihatan professional) adalah dinasihatkan merujuk laman web kesihatan yang rasmi seperti:

• MELAYU/PERUBATAN www.myhealth.gov.my/cacar-air/
• INGGERIS/PERUBATAN www.cdc.gov/chickenpox/  

"5  year old girl, was brought to clinic for having generalised vesicular rash, malaise, fever for 2 days. Also had painful oral ulcer of similar duration. reduced appetite due to painful ulcer. No GI/ URTI symptom. unsure of ill contact. Clinical examination : pink, slight malaise, T 38.3'C, Wt 16.3kg. Vesicular type rash scatterred over forehead, scalp, neck, upper chest, back, slight on the finger/upper limb and lower limb..

Fokus - Varicella infection [aka chickenpox]

Pathogen : Varicella Zoster Virus [VZV], part of Herpes Virus Group

• Primary (first time) infection will be known as Varicella infection
• after the primary infection, VZV will remain the body (sensory neural ganglia) as latent infection
• Reactivation of latent infection (secondary) will be known as Herpes Zoster infection [Shingles] 

Tramission : direct contact/ aerosol+ respiratory droplet [#highlycontagious]

• Patient is highly contagious until skin lesion (stage) had reached crusted/dry 

Incubation period

• Varicella : 14-16 days after exposure
• Shingles : 10-21 days after exposure

Clinical feature

• Rash (pluritic). 

[stage macule --> papule --> vesicular --> crusted/dry]. Usually affect head, face, neck , body, limb. But usually concentrated on chest and back.

• Malaise
• Fever (up to 102'F/38.8'C)

Healthy children --> symptom are usually mild

High risk group [infant, adult, immunocompromised] ---> severe form of symptom + complication

Recovery from primary varicella -- > lifelong immunity (re-exposure to natural wild-type VZV will only boost antibody titre -> no sign of infection / viraemia)

Unless immunocompromised [chemotherapy/HIV/ transplant] --> may induced secondary infection

Complication

• Bacterial infection of skin and subcutaneous [children]
• Pneumonia [adult]

Severe complication that may arise [usually from high risk group]

• Cerebellar Ataxia
• Encephalitis 
• Viral pneumonia
• Hemorrhagic condition
• Septicemia, Toxic shock syndrome, Necrotizing fasciitis, septic arthritis, bacterial pneumonia, osteomyelitis

"Vaccination program for varicella infection is optional (not mandatory programme) in Malaysia for age>12month.." - source infomed.com.my/vaccinationinmalaysia

Breakthrough Varicella

• occur in vaccinated children [42 days after vaccination]
• symptoms are usually milder [less fever, rash <50 spots, shorter illness duration, rash type more likely maculopapular rather than vesicular]
• patient <50 spot rash = 1/3 as contagious 
• patient <50 spot rash is just as contagious like unvaccinated

-----------------------------Management-wise (mostly symptomatic)---------------------------------

• Syrup PCM 15mg (x kg) TDS <-- for the fever
• Calamine lotion BD <-- for the itchiness
• Syrup Piriton (check dose for paeds) - for the itchiness
• Encourage orally as tolerated
• Advice isolation from other siblings/ children at school (provide MC)
• Advice short nail <-- to prevent injury from scracthing
• No need notify 

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