Rosen & Barkin's 5-Minute Emergency Medicine Consult (756 page)

• Increased risk of extracutaneous manifestations
  
• Lower immunity allows for reactivation as herpes zoster
  

• No aspirin for treatment of fever, possible association with Reye syndrome:
  
  • Acetaminophen—is recommended antipyretic treatment
    
• Parents need to be cautioned regarding risk for secondary bacterial infection and possible progression to sepsis
  

• Pregnant women with no childhood history of varicella and no antibodies to varicella zoster virus (VZV) require varicella zoster immunoglobulin (VZIG)
  
• Varicella pneumonia in pregnancy is medical emergency, associated with life-threatening respiratory compromise and death (mortality can be 10–45%)
  
• Likely to occur in 3rd trimester
  

• Thorough history:
  
  • Fever, systemic symptoms
    
  • Immunization history
    
  • Immunocompetent vs. immunocompromised
    

• Thorough physical exam:
  
  • Characterize rash spread and extent
    
  • Evaluate for any extracutaneous manifestations
    

• History and physical exam are sufficient in uncomplicated cases
  
• Pneumonitis:
  
  • CXR shows 2–5 mm peripheral densities, may coalesce and persist for weeks
    
• Reye syndrome:
  
  • Ammonia level peaks early
    
  • LFTs will be elevated
    
  • PT, PTT
    
• Cerebritis:
  
  • Lumbar puncture demonstrates lymphocytic pleocytosis and elevated levels of protein
    

• Viral culture (results in 3–5 days), polymerase chain reaction (PCR), or direct fluorescent antibody using skin scrapings from crust or base of lesion
  
• Serologic tests for varicella antibodies
  
• PCR is diagnostic method of choice, but uncomplicated patients need no labs
  

Not generally indicated unless there is concern for extracutaneous manifestations

Liver biopsy definitive test for Reye syndrome

• Impetigo
  
• Disseminated herpes
  
• Disseminated coxsackievirus
  
• Measles
  
• Rickettsial disease
  
• Insect bites
  
• Scabies
  
• Erythema multiforme
  
• Drug eruption (especially Stevens–Johnson syndrome)
  

TREATMENT

• Nonimmune transport personnel must avoid respiratory or physical contact with patients
  
• Transport personnel who have varicella or herpes zoster should not come in contact with immunocompromised or pregnant patients
  

• Airway management and resuscitate as indicated:
  
  • Protect airway if obtunded
    

• Generally, acetaminophen and antipruritics are the keys to treating classic childhood illness
  
• Closely cropped nails and good hygiene help prevent secondary bacterial infection
  
• Infants/children ≤12 yr of age:
  
  • Acyclovir:
    
    • Recommended in children taking corticosteroids, long-term salicylate therapy, or chronic cutaneous or pulmonary diseases
      
    • Modest benefit, reduces lesions by 25% and fever by 1 day
      
    • Should be given within 24 hr of symptom onset
      
    • NOT recommended in uncomplicated Varicella in healthy children
      
  • Prophylaxis with VZIG in susceptible patients:
    
    • Immunocompromised children at high risk for complication with significant exposure
      
    • Susceptible children in the same household as person with active chickenpox or herpes zoster
      
  • In 2012 FDA extended period for VZIG administration to 10 days after exposure
    
  • VZIG in short supply, difficult to obtain
    
• Adolescents/adults:
  
  • Acyclovir now recommended in adults with uncomplicated varicella initiated within 24 hr to decrease progression to disseminated disease
    
  • Symptomatic treatment with antipyretics and antipruritics
    
• Pregnant women:
  
  • If exposed to Varicella, no childhood history of varicella, no antibodies to VZV, need VZIG
    
  • 80–90% immune from prior infection, need antibody testing prior to administration of VZIG
    
  • Acyclovir or Valacyclovir prophylaxis especially during 2nd or 3rd trimesters:
    
    • Safe during pregnancy (category B)
      
  • IV acyclovir for pneumonitis/other complications:
    
    • Respiratory, neurologic, hemorrhagic rash, or continued fever >6 days
      
• Immunocompromised patients:
  
  • IV Acyclovir recommended, poor PO bioavailability
    
  • PO valacyclovir better bioavailability, approved in 2008 for lower risk immunocompromised patients
    
  • Should be started within 24 hr of onset to maximize efficacy
    
  • Foscarnet for acyclovir-resistant disease
    
  • Prophylaxis with VZIG for the susceptible immunocompromised patient
    
• Extracutaneous:
  
  • IV acyclovir or foscarnet if resistant
    
• Vaccine:
  
  • Children:
    
    • Routine vaccination for all susceptible children at 12 mo and older, 2 doses
      
  • Adolescents and adults:
    
    • Age 13 and older without history of varicella need vaccine
      
    • 2 doses separated by 4–8 wk
      
    • Recommended in high-risk groups: Health care workers, family member of immunocompromised person, susceptible women of childbearing age, teachers, military, international travelers
      
  • Post exposure prophylaxis:
    
    • Susceptible patients 12 mo or older, given with 72–120 hr, with 2nd dose at age appropriate interval
      
    • Will produce immunity if not infected
      
  • Immunocompromised persons:
    
    • Most immunocompromised persons should not be immunized
      

• Acyclovir:
  
  • Uncomplicated:
    Adults
    : 800 mg PO QID for 5 days;
    Adolescents
    (13–18 yr old): 20 mg/kg per dose QID for 7 days;
    Peds:
    20 mg/kg suspension PO QID for 5 days [max. 800 mg PO QID])
    
  • Immunocompromised:
    Adults:
    10 mg/kg IV q8h infused over 1 hr,
    or
    800 mg PO 5 times a day for 7 days.
    Peds
    : 10–12 mg/kg IV q8h infused over 1 hr,
    or
    500 mg/m
    ²
    /day IV q8h for 7–10 days
    
• Valacyclovir: 1 g PO TID for 5–7 days
  
• Famciclovir: 500 mg PO TID for 7 days
  
• Foscarnet:
  Adults
  : 90 mg/kg q12h IV over 90–120 min for 2–3 wk;
  Peds
  : 40–60 mg/kg q8h over 120 min for 7–10 days; Foscarnet is not FDA approved
  
• Hydroxyzine:
  Adults:
  25–50 mg IM or PO q4–6h.
  Peds:
  0.5 mg/kg q4–6h suspension (supplied as 10 and 25 mg/5 mL)
  
• Diphenhydramine:
  Adults
  : 25–50 mg IV, IM, or PO q4h.
  Peds
  : 5 mg/kg/d elixir
  
• VZIG:
  Adults
  : 625 IU IM.
  Peds
  : 1 vial per 10 kg IM to a max. of 5 vials [each vial contains 125 IU])
  

FOLLOW-UP

• Patients with pneumonia require admission:
  
  • ICU for respiratory observation or support
    
• Immunocompromised patients: ICU vs. ward, depending on severity of illness
  
• All admitted patients must be kept in isolation
  

• Immunocompetent children without evidence of Reye syndrome or secondary bacterial infection
  
• Adults with no evidence of extracutaneous disease
  

Patients who are discharged need close follow-up with PCP to assure resolution without complications

• Patients with varicella are infectious from 48 hr before vesicle formation until all vesicles are crusted
  
• Immunocompromised patients with Varicella need careful consideration and admission in most cases
  
• Varicella pneumonia is medical emergency, particularly in pregnancy
  

• Abramowicz M, Zuccotti G, Pflomm JM, eds. Drugs for non-HIV viral infections.
  Treatment Guidelines from The Medical Letter.
  New Rochelle: The Medical Letter, Inc. 2010;8:71–82.
  
• Albrecht MA. Treatment of varicella-zoster infection: Chickenpox.
  www.uptodate.com
  . Dec 12, 2012.
  
• American Academy of Pediatrics. Varicella-Zoster infections. In: Pickering L, ed.
  Red Book: 2012 Report of the Committee on Infectious Diseases
  , 29th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2012:774–779.
  
• Flatt A, Breuer J. Varicella vaccines.
  Br Med Bull.
  2012;103:115–127.
  
• Roderick M, Finn A, Ramanan AV. Chickenpox in the immunocompromised child.
  Arch Dis Child
  . 2012;97:587–589.
  
• van Lier A, van der Maas N, Rodenburg GD, et al. Hospitalization due to varicella in the Netherlands.
  BMC Infect Dis.
  2011;11:85.
  

See Also (Topic, Algorithm, Electronic Media Element)

Herpes Zoster

CODES