Varicella Zoster

DR.T.V.RAO MD
Varicella Zoster and
Chickenpox
Varicella-zoster virus (VZV) causes chickenpox and herpes
zoster (shingles). Chickenpox follows initial exposure to the
virus and is typically a relatively mild, self-limited childhood
illness with a characteristic exanthem, but can become
disseminated in immunocompromised children. Reactivation
of the dormant virus results in the characteristic painful
dermatomal rash of herpes zoster, which is often followed
by pain in the distribution of the rash (postherpetic
neuralgia).
Varicella Zoster
( Herpes Virus)
DNA Virus
Varicella - Chicken pox.
Contagious Disease
Mainly infects Children
Generalized Vesicular
eruptions
on Skin and Mucous
membranes
Severe manifestations in Adults
and Immune compromised.



Shingles (Herpes Zoster )

Rash Limited to
Distribution of Single
Sensory Ganglion
In Adults and immune
compromised
Sporadic

Zoster.
Associated with Immune
compromised.
Manifest with severe pain
Vesicles on trunk , head,
neck
Trigeminal Neuralgia

HERPES VARICELLA ZOSTER
HVZ
Causes chicken pox -fever + characteristic rash
variable incubation period 14-21 days
usually mild in children and more severe in adults
complications
secondary infection - uncommon
varicella pneumonia
secondary bacterial pneumonia S aureus & pneumococci
post-infetious encephalitis
generalized varicella (in immunocompromised patients)
congenital and neonatal varicella
Herpes Zoster
Primary Contact -
Chicken Pox
Reactivation -
Zoster (Partially
Immune )
Herpes zoster (shingles)
The most common presentation is the shingles vesicular rash, which most
commonly affects a thoracic dermatome
After a prodromal illness of pain and paraesthesia's, erythematous
macules and papules develop and progress to vesicles within 24 hours
The vesicles eventually crust and resolve
Pain and sensory loss are the usual symptoms
Motor weakness also occurs and is frequently missed on examination
Cases of actual monoplegia due to VZV brachial plexus neuritis have been
reported
Zoster multiplex
Shingles may appear in multiple dermatomes, both contiguous and
noncontiguous, on either side of the body
Immunocompromised individuals are more susceptible
Terminology depends on the number of involved dermatomes and
on whether the condition is unilateral or bilateral (eg, zoster duplex
unilateralis refers to the involvement of 2 unilateral dermatomes)
Cases of zoster simultaneously occurring in 7 noncontiguous
dermatomes have been reported
Properties of Virus.
Like Herpes Virus
Icosahedrons shape ds
DNA
VZV virons are spherical and 180200
nm in diameter. Their lipid envelope
encloses the 100 nm nucleocapsid of
162 hexameric and pentameric
capsomeres arranged in an
icosahedral form. Its DNA is a single,
linear, double-stranded molecule,
125,000 nt long.





Progress of events in Varicella
Zoster Infection

Culturing virus
Grows in
Human embryonic Tissue
Produce inclusion bodies
No difference in virus
In Chicken pox and zoster
infection
Pathogenesis and Pathology
Varicella virus enter through
URT/Conjunctiva.
Lymph nodes Viremia
Liver and spleen
Secondary viremia
Infects Mononuclear Cells
Rash Vesicle formation



Risk Factors
Chickenpox
Exposure to the virus if you
have not had chickenpox nor
received the vaccine
Being under 10 years of age
Time of year: late winter and
early spring is the most
common time that the virus is
spread
Shingles
Age (most common in people
over 60) Stress
Weakened immune system (for
example, people with HIV/AIDS,
or those taking drugs to suppress
the immune system due to
autoimmune diseases or organ
transplants)
Having had chickenpox before
age 1
Herpes Zoster
Skin Lesions
Inflammation of
Sensory Nerves and
Ganglia
Single Ganglion
Dorsal root Ganglion
Entry of Varicella Zoster virus

Skin lesions showing different stages

Clinical Findings.
Varicella, Incubation 10-20 days
Fever, Malaise
Rash Trunk Face Limbs
Buccal and Pharyngeal mucosa
Lesions at all stages
Macules, Papules, Vesicles, Crusts,
May last 5 days, Hundreds of
eruptions.
Skin lesions of
chickenpox

Chicken pox lesions in the buccal
cavity

Herpes Zoster involving a Nerve
segment

Other Complications.
Encephalitis,
Mother to Child
transmission
Varicella Pneumonia.
Fatal Complications.
Events in Varicella Zoster
Infection

Immune compromised
HIV / AIDS
Malignancies.
Organ transplantations
Corticosteroid usage
Leukaemia's.
HERPES VARICELLA ZOSTER
HVZ
Causes chicken pox -fever + characteristic rash
variable incubation period 14-21 days
usually mild in children and more severe in adults
complications
secondary infection - uncommon
varicella pneumonia
seconday bacterial pneumonia S aureus & pneumococci
post-infetious encephalitis
generalised varicella (in immunocompromised patients)
congenital and neonatal varicella
Pain and hyperesthesia
Pain and hyperesthesia
Ramsay-Hunt syndrome
This syndrome occurs when the
geniculate ganglion is involved. The
clinical presentation includes the
following:
A peripheral facial palsy
Pain in the ear and face Vesicles in the
external ear canal (not always present)
Additional auditory and vestibular
symptoms in some case
Keratitis (herpes
ophthalmicus)
Caused by reactivation of VZV infection in
the ophthalmic division of the trigeminal
nerve.
The presentation may include
conjunctivitis or corneal ulcers
Complications include blindness
Vesicles do not have to be present
Rarely, the virus migrates along the
intracranial branches of the trigeminal
nerve, causing thrombotic
cerebrovasculopathy with severe
headache and hemiplegia
Laboratory Diagnosis.
Smears --Scrapings from Lesions
Demonstration of Multi nucleated
giant cells
Tzanck smears
DNA Demonstration
Cell cultures,
Fluorescent antibody
ELISA PCR

Treatment
Specific treatment is indicated
mainly in Immunodeficient
and elderly subjects and also
in complicated with Varicella
pneumonia ,encephalitis,and
disseminated zoster
Acyclovir and Famiciclovir.




Antiviral Medications
Antiviral medications decrease the
duration of symptoms and the
likelihood of post herpetic neuralgia,
especially when initiated within 2 days
of the onset of rash. Oral acyclovir may
be prescribed in otherwise healthy
patients who have typical cases.
Compared with oral acyclovir, other
medications (eg, valacyclovir,
penciclovir, famciclovir) may decrease
the duration of the patient's pain.
Varicella zoster Immune
globulins
Varicella zoster immune globulin (VariZIG) is indicated for administration to high-
risk individuals within 10 days (ideally within 4 days) of chickenpox (VZV)
exposure.[4] High- risk groups include the following:
Immunocompromised children and adults
New-borns of mothers with varicella shortly before or after delivery
Premature infants
Infants less than younger than 1 year of age
Adults without evidence of immunity
Pregnant women
Epidemiology

Communicable Disease
World wide prevalence
Common in < 10 year olds.
Zoster in Adults
Droplet spread is
common

Prevention of Chickenpox

Susceptible population
children
adults living in close proximity
Do nothing
Immunize
live attenuated
vaccine
Protect if contact with patient with chickenpox
and at risk of severe disease
Zoster Immune Globulin (ZIG)
Recent advances in
research
The introduction of DNA analysis
techniques has shown some
complications of varicella-zoster to be
more common than previously
thought. For example, sporadic
meningoencephalitis (ME) caused by
varicella-zoster was regarded as rare
disease, mostly related to primary
varicella, and occurring mainly in
children or immunocompromised
people.
Approval of Vaccine by
FDA
In 2006, the United States Food and
Drug Administration approved
Zostavax for the prevention of
shingles. Zostavax is a more
concentrated formulation of the
Varivax vaccine, designed to elicit an
immune response in older adults
whose immunity to VZV wanes with
advancing age. A systematic review by
the Cochrane Library shows that
Zostavax reduces the incidence of
shingles by almost 50%
Vaccine available
A live modified Varicella virus
lyophilised vaccine which can be
stored at low temp is available for
protection
Children 1 -12 years given single
dose.>12 years 2 doses 2 -6 weeks
apart
High titre serum from convalescing
from herpes zoster protect
Immunocompromised children.
But not useful for treatment

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