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Varicella or Chickenpox
What is varicella (or chickenpox)?
What causes varicella (or chickenpox)?
Who gets varicella (or chickenpox)?
How does the varicella-zoster virus cause disease?
What are the common findings?
How is varicella (or chickenpox) diagnosed?
How is varicella (or chickenpox) treated?
What are the complications?
How is varicella (or chickenpox) prevented?
What research is being done?
Links to other information
by Philip Alfred Brunell, M.D. Senior Attending Physician Clinical Center, National Institute of Health Bethesda, Maryland
What is varicella (or chickenpox)?
Varicella, commonly referred to as chickenpox, is an infectious disease that is caused by a virus. The infection produces a rash with fluid-filled “vesicles,” or lesions, on the face and body.
What causes varicella (or chickenpox)?
The disease is caused by the varicella-zoster virus, or VZV, a member of the herpes family of viruses. As the name implies, it causes varicella, or chickenpox, as well as “zoster,” or shingles. After a recovery from varicella, the virus remains in some of the body’s nerve cells in an inactive, or “latent,” state. After many decades, the virus may become active again, travel down the nerve cells, and produce a rash on the skin. This rash is similar to the rash produced by varicella; however, the rash in zoster occurs in one segment of the skin, on one side of the body, rather than all over the body, as in varicella. Occasionally, zoster occurs in children, but it most commonly occurs in older adults.
Who gets varicella (or chickenpox)?
Varicella occurs in children. Fewer than two percent of the cases occur in adults. About half of all children will have had varicella by the time that they enter school. Varicella can occur early in infancy, and it can occur in a newborn if the mother had chickenpox just before delivery. Varicella is very contagious. If there is a case of it in a household, there is only a 1 in 25 chance that individuals in the house who are susceptible to varicella will not be infected.
How does the varicella-zoster virus cause disease?
Varicella occurs following close contact with a person who has the disease. Children are contagious the day before the rash, which suggests that they are able to spread the disease from their respiratory tract. The virus is inhaled, and then multiplies in the newly infected person. It is transported in certain blood cells to the skin, where it multiplies and causes the skin lesions, or vesicles.
What are the common findings?
The most common finding of varicella is the fluid-filled skin vesicles, usually no more than an eighth of an inch in diameter, which may have a slight redness around them. They start centrally on the body, and then spread to the arms and the legs. Often, vesicles can be felt on the scalp before they can be seen on the skin. Scabbed or crusted lesions, or a flat or slightly raised red rash, may occur at the same time as the vesicles. Often, scratch marks will result from the scratching of a very itchy rash.
The temperature is generally 100oF to 102oF. There is a cause for concern if a temperature is greater than 103oF. Fussiness may occur, caused mainly by the itching. Respiratory and gastrointestinal symptoms are not usually associated with varicella.
How is varicella (or chickenpox) diagnosed?
Varicella is diagnosed simply by looking. Laboratory testing is rarely required; although, there are tests that can be performed. Chickenpox can be confused with insect bites, hand-foot-and-mouth disease, and rickettsialpox. A history of exposure to a person with either chickenpox or shingles about two weeks previously is helpful in making an accurate diagnosis.
How is varicella (or chickenpox) treated?
Medication to treat the fever rarely is required. Aspirin or aspirin-containing medications (look for “salicylate” on the label) should never be given to children with varicella, because it has been associated with Reye’s syndrome. Acetaminophen may prolong the itching. Ibuprofen has been associated with a severe, complicated streptococcal disease, but this drug may have been given for relief of the complication, rather than for treatment of varicella; therefore, it cannot be causally related.
The itching may require treatment. Calomine lotion may be applied to the skin, or the child may bathe in an oatmeal bath (Aveno). The drying of the oatmeal on the skin after the bath may offer relief. Oral medications, such as Benadryl, also are available. Since it may cause sleepiness, Benadryl is best used at bedtime. Your doctor may recommend other oral medications, if necessary.
It is very important to keep the skin clean. Daily showers or baths, preferably with an antibacterial soap, is recommended. Phisohex is excellent, but it may be too drying. Bathing will not cause the rash to spread on the skin. The scratch marks on the skin of patients with varicella do not have vesicles, meaning that an individual cannot spread the virus by inoculating it into the skin or by bathing. It is best to prevent scratch marks by trimming a child’s nails.
Although acyclovir-a specific antiviral drug that inhibits the growth of VZV-has been approved for use in children, there has been little enthusiasm for it. It must be given within 24 hours after the onset of the rash to be effective. The effect on a person’s symptoms is minimal; however, they are statistically significant when compared to the symptoms of a person who has not had the drug. In adolescents and adults who have more severe chickenpox than children, acyclovir may be useful. The drug may be more effective in second cases in a family, where acyclovir can be obtained at the time of the first child’s illness, and treatment can be started on the other children as soon as a rash appears. Second cases tend to be more severe than the first case in a family.
What are the complications?
Most cases of varicella are mild, and can be treated by applying ointment to the skin; however, some cases may require antibiotics. Rarely, cases are very severe. If your child develops a skin infection following varicella, us should evaluate it.
The most common complication of varicella is a bacterial infection of the skin. This can occur when the fever rises after several days of illness or redness appears on the skin. The skin also may be warm and tender. In a severe infection, pain may be a prominent symptom. In recent years, streptococcal skin infections have become more frequent, and require prompt attention.
Neurologic complications do occur with varicella. The most common complication occurs 1 in about 4,000 cases, and is characterized by difficulty with balance. Although this is frightening to the child and the parents, it generally gets better by itself with time. Loss of consciousness and convulsions with fever, headache, and vomiting may indicate encephalitis. This complication occurs 1 in about 40,000 cases, but it may be life threatening. In the past, before the warning about aspirin, similar symptoms were seen in Reye’s syndrome. In any of these situations, your physician should be contacted.
There are a number of less common complications that include, among others, bleeding disorders, joint involvement, and kidney problems.
How is varicella (or chickenpox) prevented?
Avoiding contact with those individuals who are affected with chickenpox can prevent it; however, this is very difficult. Many children are not even aware that they have been exposed. Protecting children from varicella is cumbersome, as they must be kept from school and other activities.
Immunization is the only practical way to prevent varicella. A live attenuated (weakened) varicella vaccine is recommended for all children who have passed their first birthday and have not had chickenpox. Children under 12 years of age require only a single injection; adolescents and adults are given two injections. The vaccine has few side effects; tenderness or pain at the injection site is the most common. Occasionally, a child may have a few chickenpox lesions on the injection side or over the trunk. The vaccine is effective in preventing or modifying varicella. In persons who have had the vaccine and still developed varicella, their cases have been extremely mild.
There are two concerns about the vaccine: how long immunity will last, and whether zoster will be a greater problem later in life in vaccinated children than in children who actually had chickenpox. There is no reason to suspect that zoster will be a problem since children who have had the vaccine do not seem to get it more frequently, and children with leukemia who were vaccinated had zoster less frequently.
Chickenpox is a much more severe disease in adults than in children. Most children will be immunized during childhood, and it is anticipated that there will be fewer cases of varicella. Therefore, children who are not immunized during childhood will have a decreased chance of contracting chickenpox as an adult. However, children who are not vaccinated will be susceptible adults, and, if infected, may get a severe case of chickenpox. If vaccine immunity should decrease, it is likely that there may be partial immunity, which will modify the severity of chickenpox in an adult who was immunized as a child. At the present time, there is no evidence to suggest that the protection produced by the vaccine will be lost.
In persons who are exposed to varicella, the antiviral drug, acyclovir, may be given. An injection of Varicella-Zoster Immune Globulin (VZIG) is used to protect adults and children who have compromised immune systems (e.g., those receiving high doses of steroids or children with leukemia), if they are exposed to chickenpox. This injection is very expensive (about $500), and it provides protection for only a few weeks. Thus, it is necessary to give it at the time of each exposure. However, many individuals will get chickenpox following an exposure of which they were unaware.
What research is being done?
Efforts continue to find better drugs to treat varicella. In addition, basic research is being conducted to better understand why the virus becomes latent and why it becomes activated to cause zoster. Currently, there is a study, which eventually will have 37,000 participants, to determine whether a stronger varicella vaccine can prevent shingles in people over 60 years of age.
Links to other information
CDC Site for Chicken Pox
References
Brunell, P.A. Varicella-Zoster (Chickenpox) in Rudolph’s Pediatrics, 20th ed., Appleton and Lange, Stamford, CT, 1996.
Report of the Committee on Infectious Diseases, American Academy of Pediatrics, Elk Grove Village, IL, 1997.
Copyright 2012 Philip Alfred Brunell, M.D., All Rights Reserved
Varivax Immunization
http://www.cdc.gov/vaccines/vpd-vac/varicella/default.htm
Vesicoureteral Reflux
What is Vesicoureteral Reflux?
What Causes Vesicoureteral Reflux?
Who is Susceptible to Vesicoureteral Reflux?
How is Vesicoureteral Reflux Diagnosed?
What are the Symptoms of Vesicoureteral Reflux?
What are the Complications of Vesicoureteral Reflux?
How is Vesicoureteral Reflux Treated?
When is Surgery recommended for VUR?
What type of Surgery is available for VUR?
What is Vesicoureteral Reflux?
Vesicoureteral reflux is a common disorder of the urinary system. The urinary system is made up the kidneys, ureters, bladder and urethra. The body has two kidneys that drain urine to the bladder by small tubes called ureters. Urine normally travels in only one direction, i.e from the kidneys to the bladder. Vesicoureteral reflux (VUR) occurs when urine travels backward from the bladder through the ureters to the kidneys. Vesicoureteral reflux without urinary infection by in large is harmless. However, when associated with urinary infection, VUR may cause severe kidney infections (pyelonephritis) which can lead to kidney damage.
What Causes Vesicoureteral Reflux?
There are two types of VUR: primary and secondary. Primary VUR is the most common and is usually caused by an irregular embryological arrangement of the ureteral tube in the bladder early in the development of the fetus before birth. When the ureter enters the bladder, the tunnel for which it travels in the bladder may be too short or have too large of a diameter to allow the ureter to close sufficiently during bladder filling to prevent a backup of urine. This condition may resolve as the child grows with the bladder enlarging and the ureter changes in length. Secondary VUR occurs when there is an associated condition, such as: bladder outlet obstruction, overactive bladder, myelomeningocele, voiding abnormalities and dysfunctional elimination problems.
Who is Susceptible to Vesicoureteral Reflux?
VUR occurs in less than 1% of healthy children. In children with a urinary tract infection (UTI), the incidence is 25 to 50%. One study found that 38% of children with antenatal (before birth) kidney swelling (hydronephrosis) were diagnosed with VUR on subsequent studies after birth. While boys had a higher incidence antenatally, females still make up 85% of the children with VUR overall. Caucasian girls had 10 times the risk of VUR versus African-American girls.
Further studies have shown a higher incidence of VUR (30-40%) in siblings of children who were already diagnosed with VUR. If you have a child with vesicoureteral reflux, it is important to talk with your physician to determine if other siblings should be evaluated for VUR.
How is Vesicoureteral Reflux Diagnosed?
There are two different types of patients who are diagnosed with VUR; 1- children with prenatally detected kidney swelling (hydronephrosis); 2- Children being evaluated for urinary tract infection. Some children are detected before birth when hydronephrosis is discovered via a prenatal screening ultrasound. These children are frequently evaluated after birth with a renal ultrasound and voiding cystourethrogram (VCUG). A VCUG is performed by placing a catheter in the urethra (natural voiding channel) and X-ray visible dye is injected into the bladder allowing X-rays to delineate the flow of the urine.
The second group of children may require an evaluation for VUR after a urinary tract infection. While opinions vary, it is generally accepted that the following children with a UTI should be evaluated for VUR with a renal ultrasound and VCUG: any child less than 5 years of age, a child with a UTI and fever (regardless of age), and any boy with a UTI (unless they are sexually active or have a significant past history of genitourinary problems).
Your healthcare provider may recommend another form of imaging called a radionuclide scan. This procedure allows the provider to continue to monitor the VUR with minimal radiation exposure. A DMSA scan may be ordered to detect scarring of the kidney or an infection in the kidney (pyelonephritis).
The VCUG is important in helping to stage the severity of VUR.
Grade I: urine refluxes into the ureter only
Grade II: urine refluxes into the ureter and renal pelvis (collecting system of the kidney) without distention of the pelvis.
Grade III: urine refluxes into the ureter and renal pelvis with only mild dilatation (hydronephrosis)
Grade IV: the child also has moderate hydronephrosis
Grade V: The child has severe hydronephrosis and abnormalities of the ureter.
What are the Symptoms of Vesicoureteral Reflux?
Vesicouretral reflux itself is usually asymptomatic and a urinary infection is the presenting picture. Children may present initially with the following signs of a urinary tract infection: fever, malodorous urine, blood in the urine, urinary frequency, pain with urination, bedwetting, protein in the urine, lethargy or gastrointestinal symptoms. Newborns may have nonspecific symptoms such as poor feeding and irritability.
What are the Complications of Vesicoureteral Reflux?
Vesicoureteral Reflux without urinary infection for the most part does not cause injury to the kidneys. However, VUR with infection can result in an infection of the kidney (pyelonephritis) which can result in scarring of the kidney. Fortunately, significant kidney scarring is rare. Significant scarring of the kidneys can result in high blood pressure, renal impairment, renal failure, and complications in pregnancy as an adult. Prophylactic antibiotic treatment to prevent urinary infections in children is begun immediately after diagnosis of VUR to try and decrease the risk for these complications.
How is Vesicoureteral Reflux Treated?
The management and treatment of VUR depends upon many factors and an in depth discussion of VUR and your child should be individualized with your health care provider. Vesicoureteral reflux is frequently initially managed by a primary care provider for lower grades of VUR (1-3) . Higher grades of VUR or complex and complicated cases of VUR are usually jointly managed with a surgical specialist called a Pediatric Urologist.
VUR has a spontaneous resolution rate and is usually managed with prophylactic antibiotics (preventative antibiotic) in hope that with growth of the child there will be concomitant growth of the ureteral tunnel. Should the tunnel grow enough then the VUR may resolve without the need for a surgical procedure. Prophylactic antibiotics are given at very low doses daily to reduce possible side effects. Newborns are usually given Amoxicillin or Keflex (Cephalexin). Children older than 2 months can be given Trimethoprim (Primsol) or Bactrim (trimethoprim-sulphamethoxazole). Waiting 12-18 months is the usual time to wait between follow up X-rays so that a child has time to grow.
Spontaneous resolution of VUR has one major caveat. It is impossible to predict when or if the VUR will improve or resolve. Some children with high grade VUR can have resolution in a short time frame and some children with low grade VUR will never have spontaneous resolution. Fortunately most children with Grades I-III VUR will have improvement or resolve their urinary reflux by the time they are 2 to 5 years of age. Children with Grades IV & V urinary reflux have a lower resolution rate of VUR. These children too can be followed but frequently require a surgical procedure to bring closure to the VUR
When is Surgery recommended for VUR?
If a child has a breakthrough infection (urinary tract infection on the preventative antibiotic) the conservative plan of monitoring the reflux must be abandoned and a surgical procedure is necessary to prevent further potential infections of injuring the kidneys. In general infants are at greater risk for renal injury than older children.
Surgery is also an option if a child has had persistent VUR after years of follow-up with little or no improvement. However, if no infections have occurred surgery is not mandatory. In the older child, many families frequently select surgery to bring closure to the problem, allow the discontinuance of antibiotics, and avoid any further potential side effects of VUR.
What type of Surgery is available for VUR?
Surgical treatment is offered in 2 ways; open ureteral reimplantaion surgery and minimally invasive endoscopic deflux injections. The gold standard is open surgery that involves rearranging the ureters in the bladder in a non-refluxing natural position. Open surgery is > 95% successful and usually does not require a repeat VCUG x-ray after surgery. The surgical procedure is performed through a 4cm low abdominal incision, just above the pubic bone, below the underpants line. The child routinely only spends the night of surgery in the hospital and generally gets back to normal activity in 3-5 days (4-6 years old). Infants and toddlers rarely need surgery but, if required, are frequently back to themselves within 1-2 days.
Minimally invasive deflux injection involves performing a telescopic exam (endoscopic) of the bladder through the urethra as an outpatient procedure. This access allows direct injection of a dextramoner bead paste (sugar beads) under the ureter that improves or cures VUR in about 80% of the time. Children are back to normal activity usually the same day. A VCUG x-ray is necessary to assess the treatment after the procedure.
About the Author
Peter D. Furness III, M.D., FAAP, FACS:
Dr. Furness is Associate Professor of Surgery and Pediatrics at the University of Colorado Health Sciences Center and the Associate Chief of Pediatric Urology at the Children’s Hospital in Denver, Colorado.
Copyright 2012 Peter D. Furness III, M.D., All Rights Reserved
