Case Presentation- A Case of Chickenpox.pptx

Clinical case presentation of a case of Chickenpox

1. Case Presentation on Chickenpox Presentation By- Dr. Sohan Khanna (JR2) Guided By- Dr. Rajeev Yadav Dr. Manoj Gupta This Photo by Unknown Author is licensed under CC BY-SA

2. Demographic Data Name- XYZ Age-10 yrs. Sex- Male Religion - Hindu Address- Shahpura, Distt.-Jaipur Occupation-Student

3. Chief Complaints Fever since last 4 days Headache since last 4 days Rash since last 2 days

4. History of Present Illness The patient was apparently asymptomatic 4 days back when he presented in emergency department of J.K. Lon Hospital, Jaipur with moderate fever associated with shivering and headache since 4 days. Patient also complained of rash since 2 days which was first noticed on the trunk. The rash was also present on arms and legs. The patient also complains of itching over rash.

5. History of Past Illness P atient has no history of similar complaint s in the past. No history of TB, asthma or any other medical illness. No history of any major or minor surgery in the past. No history of any allergy known to patients’ parents Allergic History

6. Personal History- Patient is non-vegetarian, his sleep pattern is normal, bladder and bowel habits are normal. Birth History- Prenatal – Uneventful Natal- Full term normal Vaginal Delivery, home delivery Cried at birth immediately Birth weight – 2800g Birth length – Don’t know Postnatal - Uneventful

7. History of Breast Feeding and Complimentary Feeding- Child was exclusively breast fed for 7 months Complimentary feeding started at 7 th month Weaning – bananas and khichdi was given Growth Development- Child start to stand when he is around 1 year old Start to walk at 2 year old Start to speak when he is 1.5 year old All milestone was up to date to his age Immunization History- Immunization card is not available. His mother does not remember vaccination details except that OPV was given. Last dose of which was when the patient was 5 years old.

8. Family History- He is the eldest son of a non consanguineous marriage between 30 years old father and 25 year old mother. He has 1 younger sister who is not experiencing similar symptoms currently. There is no family history of congenital anomaly Contact History- There is no history of similar complaints in patients’ family and neighborhood.

9. General Physical Examination General Examination: Poor Semi-conscious and oriented to time place person No dehydration Temp.- 39.5 º C (Febrile) Built – thin Height – 135cm Weight- 30kg Facial features are normal. B.P-110/72 mm of Hg P.R-100/min R.R-42/min O2 saturation-98% on room air No cyanosis, pallor, clubbing, icterus, lymphadenopathy and edema

10. Socioeconomic History Total members of family - 4 The patient’s father is a shopkeeper and has studied till 12 th class. The patient’s mother is a housewife and is uneducated. Child lives in a nuclear family. Total family income-Rs. 30,000/month Per capita income-Rs. 7 500/person Lives in a pakka house with two rooms ,a separate kitchen and separate toilet and bathroom.

11. Local Examination Multiple Maculopapular rash seen on Head, Face, Neck, Trunk, Arms and legs Sc ratch Marks seen near the site of rash Oral Cavity - Poor hygiene Nose: NAD Bilateral Ears: NAD

12. Systemic Examination CNS- Normal sensorium O riented to time place and person. Bilateral pupils react to light Respiratory System: Air entry equal on both sides P/A - Soft ,non tender, umbilicus inverted and central and no signs of organomegaly & bowel sounds heard on auscultation CVS- S1 S2 heard, no murmur present

13. Investigations Hb- 13.6 g/dL P latelet count-1,80,000/mm 3 Advised tests – CBC RFTs LFT s Serum electrol ytes Urea, Creatinine Chest X-Ray

14. Diagnosis Provisional- Child was provisionally diagnosed as case of Chickenpox Confirmatory Diagnosis- The lab diagnosis is rarely required. It can be done by- Detecting VZV DNA using PCR or isolating VZV in cell culture from vesicular fluid, crusts, saliva, cerebrospinal fluid or other specimens. Direct immunofluorescence Detection of VZV-specific serum lgM antibody - not the method of choice for confirming varicella. Detection of serum lgM and PCR are of limited value for the confirmation of HZ. Serologic screening of serum for lgG antibodies to assess immunity or susceptibility to varicella in unvaccinated persons, e.g. in health-care workers.

15. Differential Diagnosis Smallpox Herpes Simplex Enterovirus Bullous Impetigo Drug Reactions Contact Dermatitis Insect Bites

16. Smallpox Chickenpox 1. Incubation: About 12 days (range: 7-17 days) About 15 days (range 7-21 days) 2. Prodromal/ symptoms: Severe Usually mild 3. Distribution of rash : centrifugal palms and soles frequently involved axilla usually free rash predominant on extensor surfaces and bony prominences centripetal seldom affected axilla affected rash mostly on flexor surfaces. 4. Characteristics of the rash: deep-seated vesicles multilocular and umbilicated only one stage of rash may be seen at one time No area of inflammation is seen around the vesicles. superficial unilocular; dew-drop like appearance rash pleomorphic, i.e., different stages of the rash evident at one given time, because rash appears in successive crops an area of inflammation is seen around the vesicles 5. Evolution of rash: evolution of rash is slow, deliberate and majestic, passing through definite stages of macule, papule, vesicle and pustule. (b) scabs begin to form 10-14 days after the rash appears Evolution of rash is very rapid scabs begin to form 4-7 days after the rash appears 6. Fever subsides with the appearance of rash, but may rise again in the pustular stage (secondary rise of fever). Temperature rises with each fresh crop of rash

17. During the first day or two of rash, it may be impossible, from the rash alone to differentiate smallpox from chickenpox

18. On day 3, the rash associated with each of the diseases continues to look very similar

19. By Day 5, all of the smallpox lesions are at the same stage of development However, patient with chickenpox shows different stages of rash-papules, vesicles, pustules

20. By day 7, no formation of scabs in smallpox lesions Most of chickenpox lesions have already formed scabs, and some scabs, in fact, have already separated

21. By day 10, smallpox scabs have just begun to form In chickenpox, most of the scabs have fallen off by day 10 (in chickenpox, scabs begin to form as early as day 3 or 4, and fall off by day 14)

22. Smallpox- pocks are more dense on arms and legs than trunk Chickenpox- pocks are more on back compared to arms and legs

23. Herpes Simplex Enterovirus Bullous Impetigo

24. Drug Reactions Contact Dermatitis Insect Bites

25. Management The patient presented to Emergency of JK Lon Hospital where he was given the following treatment- Tab. PCM 15 mg/kg TDS Tab. Antihistaminic HS and Calamine lotion over rashes for itching Oral Acyclovir 10-20 mg/kg QID Tab. Amoxyclav 10 mg/ kg orally TDS or i.v. 25 mg/kg

26. About the Disease Caused by varicella-zoster (V- Z) virus Based on the host response, it can manifest either as chickenpox or shingles Chickenpox (common in children) and Shingles (common in adults) Worldwide distribution Occurs in both epidemic and endemic forms

27. Problem Statement Global Burden - In the pre-vaccine era in high-income developed countries, CFR was about 3/1,00,000 cases Global annual chickenpox disease burden includes 4.2 million severe complications leading to hospitalization and 4,200 deaths Burden in India – No. of cases = 66, 963 and No. of deaths = 50 (as per National Health Profile, 2019)

28. Epidemiology Agent : V- Z virus aka "Human (alpha) herpes virus 3". Recovery from primary infection (Chickenpox) is f/b establishment of latent infection in cranial nerves, sensory, ganglia, and spinal dorsal root ganglia, often for decades, without clinical manifestations. When CMI wanes with age or following immune-suppressive therapy, the virus may reactivate, resulting in herpes zoster in about 10- 30 % Herpes Zoster is painful, vesicular, pustular eruption in distribution of ≥1 sensory nerve roots. The virus can be grown in tissue culture.

29. Source of infection : Usually a case of chickenpox. The virus occurs in the oropharyngeal secretions and lesions of skin and mucosa. Rarely, patient with herpes zoster. The virus can be readily isolated from the vesicular fluid during the first 3 days of illness. Scabs are non-infective. Infectivity : 1-2 days before the appearance of rash, and 4 to 5 days thereafter The virus tends to die out before the pustular stage. The patient ceases to be infectious once the lesions have crusted. Secondary Attack Rate : about 90%

30. Host Factors (a) Age : primarily among children <10 years age. Few persons escape infection until adulthood. The disease can be severe in normal adults. (b) Immunity : One attack gives durable immunity; second attacks are rare. The maternal antibody protects the infant during the first few months of life. No age, however, is exempt in the absence of immunity. The IgG antibodies persist for life and their presence is correlated with protection against varicella. The CMI appears to be important in recovery from V- Z infections and in protection against the reactivation of latent V-Z virus

31. (c) Pregnancy : Infection during pregnancy presents a risk for the fetus leading to congenital varicella syndrome. It occurs in 0.4-2.0 % of children born to mothers who become infected with VZV during the first 20 weeks of gestation. Infants, whose mothers had chickenpox during pregnancy, have a higher risk of developing herpes zoster in the first years of life

32. Transmission Reservoir – Humans (Respiratory tract before symptom onset, vesicular fluid, in nervous system after rash resolves) Infective Material – Oropharyngeal secretions Portal of Entry – URT or conjunctiva and close personal contact Portal of Exit – URT by droplet nuclei Transplacental route Mode of transmission – when infected person sneezes, tiny droplets are released which are inhaled by non-immune person IP – 10-21 days

33. Control Controlling Source - notifications, isolation of cases for about 6 days after onset of rash (till the crusts fall off) and disinfection of articles soiled by nose and throat discharges Period of Isolation – from 10 th day to 21 st day post-exposure or until 28 th day if exposed individual receives VZIG. Protection of Susceptible Host – Acyclovir given orally (>12 years age) or i.v (complicated varicella, immunocompromised, recurrent zoster) within 24 hours of onset of rash.

34. Prevention Avoid healthy children and adults coming in contact with a case of chickenpox Infected child should not attend school for a week Wear surgical mask Trimming nails would prevent spread of virus Disinfect hands, clothes, and household surroundings Do not put finger in mouth or rub eyes after touching infected person

35. Pre-Exposure Vaccination Live attenuated varicella virus vaccine (not yet been introduced in National Immunization Program) 1-12 years age : 1 dose 0.5 ml s/c > 12 years age : 2 doses 6-10 weeks apart Post-partum mothers : 1 st dose - after delivery and before discharge from hospital 2 nd dose – 4-8 weeks after the 1 st dose Women who get varicella vaccine can breastfeed

36. Combination Vaccines (MMRV) - can be administered to children from 9 months-12 years. If 2 doses of MMRV are used, the minimum interval between doses should be 4 weeks. It is preferred that the 2nd dose be administered 6 weeks to 3 months after the first dose or at 4-6 years of age. 2 doses of vaccine are about 90% effective at preventing chickenpox for 10 years. Adverse reactions can occur as late as 4-6 weeks after vaccination. Tenderness and erythema at the injection site seen in 25%, fever in 10-15%, and a localized maculopapular or vesicular rash in 5%: a smaller percentage develops a diffuse rash, usually with five or fewer vesicular lesions.

37. Spread of virus from vaccinees to susceptible individuals is possible, but the risk of such transmission even to immuno-compromised patients is small, and disease, when it develops, is mild and treatable with acyclovir. Being live attenuated virus vaccine, it should not be given to immunocompromised individuals, or pregnant women. The use of varicella vaccine may be considered in clinically stable HIV-infected children or adults with CD4+ T-cell levels ≥15 % including those receiving HAART (2 doses are recommended). HIV testing is not a prerequisite for varicella vaccination. It is C/I in persons allergic to neomycin. It is recommended that following vaccination, salicylates should be avoided for 6 weeks (to prevent Reye's syndrome).

38. Post-Exposure Vaccination One dose within 72 hours of exposure will prevent varicella to extent of 98% and up to 70% after 5 days Vaccination can be given after 72 hours because it can modify disease or provide protection against future exposures VZIG is effective in reducing the severity when given 96 hours after exposure Dose – 125 U/kg body wt. up to 625 U/person Decision is based on – (a) whether susceptible (b) exposure is likely to result in infection (c) risk of complications is more than general population

39. Complications of Varicella Secondary bacterial infection of lesions Cellulitis, Lymphadenitis and Subcutaneous Abscess Varicella Gangrenosa from Strep. Pyogenes- a life threatening infection

40. Complications of Varicella Bacteremia causing pneumonia, arthritis and osteomyelitis CNS manifestations-Encephalitis and Cerebellar ataxia Varicella hepatitis Acute thrombocytopenia, accompanied by petechiae, purpura, hemorrhagic vesicles, hematuria and GI bleeding Nephritis, Nephrotic Syndrome and HUS

41. This Photo by Unknown Author is licensed under CC BY Thank You….