CASE PRESENTATION

CHICKEN POX

DEFINITION/DESCRIPTION

What is Chicken Pox?

Chickenpox is a very contagious disease caused by the varicella-zoster virus (VZV).

•Varicella is an acute infectious disease; it is caused by varicella-zoster virus (VZV), which is a

DNA virus that is a member of the herpesvirus group.

•After the primary infection, VZV stays in the body (in the sensory nerve ganglia) as a latent
infection.

•Primary infection with VZV causes varicella.

PATHOPHYSIOLOGY

Chickenpox is usually acquired by the inhalation of airborne respiratory droplets from an

infected host.

•The highly contagious nature of varicella-zoster virus (VZV) underlies the epidemics that
spread quickly through schools.

•The varicella-zoster virus (VZV) is the etiologic agent of the clinical syndrome of chickenpox
(varicella).

•After initial inhalation of contaminated respiratory droplets, the virus infects the conjunctivae
or the mucosae of the upper respiratory tract.

•Viral proliferation occurs in regional lymph nodes of the upper respiratory tract 2-4 days after
initial infection; this is followed by primary viremia on postinfection days 4-6.

•A second round of viral replication occurs in the body’s internal organs, most notably the liver
and the spleen, followed by a secondary viremia 14-16 days post infection.
•This secondary viremia is characterized by diffuse viral invasion of capillary endothelial cells
and the epidermis.

•VZV infection of cells of the malpighian layer produces both intercellular edema and
intracellular edema, resulting in the characteristic vesicle.

•Exposure to VZV in a healthy child initiates the production of host immunoglobulin G (IgG),
immunoglobulin M (IgM), and immunoglobulin A (IgA) antibodies; IgG antibodies persist for life
and confer immunity.

•After primary infection, VZV is hypothesized to spread from mucosal and epidermal lesions to
local sensory nerves.

•VZV then remains latent in the dorsal ganglion cells of the sensory nerves.

Reactivation of VZV results in the clinically distinct syndrome of herpes zoster (shingles).

CLINICAL MANIFESTATION

Chickenpox infection appears 10 to 21 days after exposure to the virus and usually lasts about
five to 10 days.

•Rash. Once the chickenpox rash appears, it goes through three phases: raised pink or red
bumps (papules), which break out over several days; small fluid-filled blisters (vesicles), forming
from the raised bumps over about one day before breaking and leaking; and crusts and scabs,
which cover the broken blisters and take several more days to heal.

•Fever. Fever is an accompanying symptom of chicken pox.

•Headache. Headache may appear one to two days before the rash.

•Body malaise. There is a feeling of generalized tiredness all over the body.

DIAGNOSTIC PROCEDURE OR TEST

Health care providers could readily diagnose varicella by doing a clinical assessment.

•Polymerase chain reaction (PCR) testing. The most sensitive method for confirming a
diagnosis of varicella is the use of PCR to detect VZV in skin lesions (vesicles, scabs,
maculopapular lesions).

•IgM testing. IgM testing is considerably less sensitive than PCR testing of skin lesions;
commercial IgM assay may not be reliable and false negative IgM results are not uncommon; a
positive IgM ELISA result, although suggestive of a primary infection, does not exclude re-
infection or reactivation of latent VZV.

•Paired acute and convalescent sera. Paired acute and convalescent sera showing a four-fold
rise in IgG antibodies have excellent specificity for varicella, but are not as sensitive as PCR of
skin lesions for diagnosing varicella.

•Blood testing. Most children with varicella have leukopenia in the first 3 days, followed by
leukocytosis; marked leukocytosis may indicate a secondary bacterial infection but is not a
dependable sign; significant elevations of alanine aminotransferase (ALT) occur in 20-50% of
children and adolescents with varicella complicated by hepatitis, but elevations return to
normal within one month in almost all cases.

•Tzanck smear. A Tzanck smear involves scraping the base of the lesions and then staining the
scrapings to demonstrate multinucleated giant cells; the presence of multinucleated giant cells
suggests a herpes virus infection but is not specific for varicella-zoster virus.

•Immunohistochemical staining. Immunohistochemical staining of skin lesion scrapings can

confirm varicella.

MEDICAL MANAGEMENT

The symptoms of chickenpox in the pediatric population can be treated topically and with oral
agents.

•Antiviral therapy. The routine use of acyclovir or valacyclovir in healthy children is

recommended by the AAP if it can be given within 24 hours after the rash first appears in
children older than 12 years, those with chronic cutaneous or pulmonary disorders, those on
long-tern salicylate therapy, and children receiving corticosteroids.
•Varicella zoster immune globulin. Varicella zoster immune globulin (VariZIG by Cangene) was
approved by the FDA in December 2012; it is indicated for high-risk individuals within 10 days
(ideally within 4 days) of chickenpox exposure; this agent reduces complications and the
mortality rate of varicella, not its incidence.

•Antibiotic therapy. Suspicion of secondary bacterial infection should prompt early institution
of empirical antibiotic therapy until the results of culture studies become available.

NURSING MANAGEMENT

Interventions for a child with chicken pox include:

•Patient education. Educate parents about the importance and safety of the Varicella Zoster
vaccine.

•Manage pruritus. Manage pruritus in patients with varicella with cool compresses and regular
bathing; warm soaks and oatmeal or cornstarch baths may reduce itching and provide comfort.

•Trim fingernails. Trimming the child’s fingernails and having the child wear mittens while
sleeping may reduce scratching.

•Dietary measures. Advise parents to provide a full and unrestricted diet to the child; some
children with varicella have reduced appetite and should be encouraged to take sufficient fluids
to maintain hydration.

DRUG OF CHOICE

Acyclovir is used to decrease pain and speed the healing of sores or blisters in people who have
varicella (chickenpox), herpes zoster (shingles; a rash that can occur in people who have had
chickenpox in the past), and first-time or repeat outbreaks of genital herpes (a herpes virus
infection that causes sores to form around the genitals and rectum from time to time).
Acyclovir is also sometimes used to prevent outbreaks of genital herpes in people who are
infected with the virus. Acyclovir is in a class of antiviral medications called synthetic nucleoside
analogues. It works by stopping the spread of the herpes virus in the body. Acyclovir will not
cure genital herpes and may not stop the spread of genital herpes to other people.

Brand names

•Sitavig
•Zovirax : Capsules

•Zovirax : Tablets

Other names

•Acycloguanosine

•ACV

Acyclovir may cause side effects.

•upset stomach

•vomiting

•diarrhea

•dizziness

•tiredness

•agitation

•pain, especially in the joints

•hair loss

•changes in vision

REFERENCE

Nurselabs.com/chicken-pox-varicella/

MedlinePlus.gov/druginfo/meds.html