Infections Associated with Vesicular Exanthem

(James B. Dellava and Mamae Violata)

1) VARICELLA (Chickenpox)

Varicella is a benign, self-limiting, and highly communicable infection in children but

associated with severe infections in adults.

Etiologic Agent
The causative agent is the Varicella-Zoster Virus (VZV), a double-stranded,
enveloped DNA virus that belongs to the Herpesvirus family of viruses.

Mode of Transmission
The disease is most commonly transmitted by inhalation of respiratory droplets
but may also be transmitted by direct contact with the lesions.

Clinical Findings
Varicella is characterized by fever and vesicular eruptions on the skin and mucous
membranes. The vesicles rupture and ulcerate and later leads to scab formation (crusts). The
vesicales are described as “teardrop on a pink base” or “dew drop on a rose petal.”

Laboratory Diagnosis
Diagnosis is based on clinical manifestations and a Tzanck smear of skin
scrapings or swab from the vesicle to demonstrate the Cowdry type A inclusions and
multinucleated giant cells.

Treatment and Prevention

The treatment is mainly symptomatic. The drug acyclovir has been shown to be
effective in reducing the course of the disease but it does not prevent latency and recurrent
infections. Prevention is by administration of Varicella-Zoster Virus vaccine, a live attenuated
vaccine.

2) HERPER ZOSTER (Shingles)

Zoster or shingles is a disease that occurs in adults or immunocompromised individuals

and is caused by the same virus that causes chickenpox. It is cause by the reactivation of a latent
chickenpox infection. The first manifestation is severe radicular pain over the skin supplied by
sensory ganglia.
3) VARIOLA (Smallpox)

Variola or smallpox is a contagious infection responsible for very high fatality rate
worldwide before the 18th century. For centuries, smallpox was controlled through the process
known as variolation, which involved inoculation of high-risk individuals with live virulent
virus. The process was relatively dangerous but greatly helped reduce the rate of outbreaks and
epidemics. It was Edward Jenner who developed a live vaccine from cowpox in the 17 th
century.

Etiologic Agent
The etiologic agent is the Variola Virus, a member of the human Poxviruses.
Poxviruses are the largest among the DNA viruses. It shares antigenic determinants with animal
poxviruses and because of this, the Cowpox virus has been successfully used in the development
of vaccines for smallpox.

Mode of Transmission
The primary mode of transmission is through inhalation. It can also be
transmitted by direct contact with the lesions, dried virus, or contaminated materials like
clothing.

Clinical Findings
There are two variants of smallpox---smallpox minor (1% mortality) and
smallpox major (up to 40% mortality). The disease initially presents with fever and malaise,
followed by the appearance of rashes that are macular that then become popular, later becoming
vesicular, and eventually pustular.

Table 23.2 Comparison between Chickenpox and Smallpox

Features Varicella Variola

Common Name Chickenpox Smallpox
Mode of Transmission Inhalation, direct contact Inhalation, direct contact
Exanthem Vesicular Vesicular
Lesions appear one stage at a
Eruptions of Lesions Crops of different stages
time
Scar Formation Rare Common
Latency Yes No
 Children: mild, self-limited
Severity Generally server and fatal
Adults: severe
Vaccine Yes Yes
Laboratory Diagnosis
The disease is easy to recognize based on the symptoms. Virus isolation can be
done by growing of the virus in chorioallantoic membrane of embryonated eggs where the
characteristic pocks develop. Antibody assays can confirm the diagnosis.

Treatment and Prevention

Methisazone is effective as prophylaxis but not for the therapeutic purposes. The
vaccine is a live, attenuated vaccine. Smallpox has been totally eradicated since 1980 because of
the success of vaccination.