Long Case Report

A Full-term Neonate Appropriate for Gestational Age with

Neonatal Varicella

Susi Handayani

National Board Examination

Jakarta, 5th-6th Mei 2018

INDONESIAN COLLEGE OF PEDIATRICS

APPROVAL LETTER
LONG CASE REPORT
 Susi Handayani
04022781319006

It has been approved to submitted to National Board Examination

By:
Chairman of the Pediatric Program
Faculty of Medicine Sriwijaya University

Dr. Aditiawati, SpA(K)

TIMELINE DIAGRAM

30thMarch 2018 1th April 2018 6 ndApril 2018

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 Patient admitted Initial observation by Report
to the candidate
NEO
at Hospital X

PATIENT’S RECORD FOR NATIONAL BOARD EXAMINATION

5th-6thMei 2018
Candidate: Susi Handayani
Patient’s Identity Parent’s Identity
Name : BO. Mrs. I Father’s name : Mr. SM
Gender : Male Father’s age : 29 years old
Age : 16 days Father’s education : Bachelor
Date of birth : March14th,2018 Father’s occupation : Hotel clerk
Hospital admission : March 30th, 2018
Mother’s name : Mrs. IM
Initial observation by candidate began on Mother’s age : 28 years old
April 1th, 2018 Mother’s education : Bachelor
Mother’s occupation : Housewife

PATIENT’S HISTORY (History was taken from patient’s parents)

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Chief complaint : Fever
Additional complaint : multipel vesicles throughout the body

History of the Disease (aloanamnesis, the patient's mother, Marchth-14th, 2018)

A baby boy was born from a G3P2A0 mother, 39 weeks of gestation by aspontaneous
delivery by Midwife,birth weightwas 3000 grams, body length was 49 cm, and head
circumference was 35 cm, the baby cried spontaneously, APGAR score was 8/9. There were
nochorioamnionitis and risk factors such as premature rupture of membrane, greenish, thick,
and foul smelling amniotic fluid, white/vaginal discharge and burning sensation when
urinating during the pregnancy. The amount of amniotic fluid at delivery was unknown,
placental weight was about 350 grams. Laboratory findings of the mother were not note, The
babywas diagnosed with a full-term neonate appropriate for gestational age (FT -AGA).
At 12 days of age, maculo papul and vesicular lession began on the tighh, round shaped filled
with clear water like teardrops. The lession spread to the buttocks and later to other areas of
the body. The baby was brought to the physician and was given paracetamol buthadnot
improvement. At of age 14 days the vesicles and papules spread throughout the face and
body and baby developed fever but not too high, temperature was not measured, the baby
become irritable . He was brought to Emergency Room of MH, and then transferred to the
Neonatal isolation room and was planned to have laboratory examination.
The laboratory result were hemoglobin 13.3 g/dL, leukocyte 9.1x103/mm3, thrombocyte 210
x103/mm3, diff count 0/0/62/33/5, C-reactive protein (CRP) <5 mg, IT ratio 0.08, and ESR 2
mm/hour. Based on these results, the baby was diagnosed with a full-term neonate
appropriate for gestational age (FT-AGA) with neonatal varicella and suspected
infection. The baby was treated with dextrose 10% with sodium, and acyclovir 3x 50 mg iv,
ampicillin 3 x 80 mg iv, gentamicin 2 x 8 mg iv.
Atthe second day of hospitalization, his condition was improved, there was no more fever,
some vesicles had ruptured and dried, and treatment was still continued.

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Socio-Economic, Psychological, and Environmental History
The mother is 28 years old, housewife, Moslem, from X ethnicity, she had a bachelor degree.
The father is 29 years old, a Moslem, also from X ethnicity, graduated with bachelor degree,
currently working as ahotel clerk with salary around IDR3,000,000 per month. There is no
consanguity between parents. They live in an urban area in X city, at their own permanent
house, with size of the house is around 35 m2 with two bedrooms, a bathroom, a living room,
and a kitchen. The house has sufficient ventilation. The electricityis provided by PLN
(Perusahaan Listrik Negara) whilewater for drinking, and washing is provided by PDAM.
The nearest mosque is around 150 metersfrom the house while access to public
transportation, health care facility and school isaround 500 meters. The family life generally
was going well. Father is the sole source of family income. The health care cost for the
patient was covered by the Indonesian Universal Healthcare Insurance (BPJS).
Conclusion:low to middle socio-economic status.

History of pregnancy and birth

The baby is an expected child, his mother had routine pregnancy check-up to a midwife or an
obstetrician, with the last visit at the third trimester. There was no History of miscarriage. In
the current pregnancy, one day before delivery mother noticed nodules dan vesicles in her
hand, she was brought to dermatologiest and diagnosed with varicella was given acyclovir
per oral, acyclovir ointment, paracetamol, there were no fever, icterus, hypertension, diabetes
mellitus, and white vaginal discharge. Mother had body weight increase of 10 kg during the
pregnancy. Mother’s nutritional intake was adequate, she ate three times per day, with a half
full portion and twice snack.At 8 months of pregnancy, her first child had chicken pox for 5
days and was given some medicine.
Conclusion: there was history of varicella in the family.

History of Immunization
The patient had been given Hepatitis B0 and Polio immunization.

Nutritional history
The baby had breastmilk only on day one, and then the baby was given formula milk in
while been hospitalized and combined with parenteral nutrition with dextrose 10% and
sodium. Body weight was monitored every day, while the length and head circumference

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were monitored once a week. The baby had weight loss around 5% during the first week of
life.

Conclusion: there was a reduction of body weight but still within normal limits.

PHYSICAL EXAMINATION
Taken on age 15 day. (taken in day 3 in hospilazation). The patient looked actived.
Vital Signs
- Heart rate :150 bpm, regular, adequate volume and pressure
- Respiratory rate : 48 times/minute, regular, no retraction
- Temperature (axilla) : 37,1oC
- Saturation of oxygen : 98 – 99% (without O2suplementation).
Nutritional status and anthropometric measurements
- Body weight : 3.000 g (birth weight 3000 g)
- Body length : 49 cm
- Head circumference : 35 cm

General Examination
System Description
Skin Multiple vesicles like tear drop appearance (+), crusta (+), Icteric
Head (-))))),anemic
The size of the(-),
headcyanosis (-)
was normal, no deformity, open and flat fontanel, the
front fontanel size about 2.1 cm x 2.1 cm, and the head circumference was
35 cm
Hair Black,not easily pluckable.
Face Symmetrical, not dysmorphic, no cranial palsy
Eyes Isochoria pupils with diameter around 3mm/3mm, normal light reflex.
anemic conjunctiva (+).

Nose There was no nasal flare

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 Ears No discharge, no deformity, open ear canals
Mouth Moist mucose, good sucking reflex, no central cyanosis

Chest Symmetrical chest,no visible retractions. No vertebral deformity.

Lungs Symmetrical respiration, normal vesicular, no rales, no additional

breathing sound and no wheezing
Heart .No ictus cordis visible, no thrill.In auscultation, normal I and II sounds, no
murmurs and gallops
Abdomen Flat, liver and spleen are not palpable, shifting dullness not exist, normal
bowel sounds, there is no umbilical hernia found
Back No deformity
Anal No deformity
Genitalia Male, testis +/+, fimosis (-)
Extremity Warm, no swelling, capillary refill time <3 seconds
Lymph node No lymphadenopathy on axilla and bilateral inguinal
Neurological Normal physiological reflex on all extremities, tonic neck reflex was
status normal, palmar grasp and plantar grasp reflexes were present, normal
sucking reflex, and normal muscle tone.

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LABORATORY EXAMINATIONS
Table 1. Complete Hematologic and Immuno-serologic Examinations
Examination Referred Standard Age 14 day old

Hb (g/dl) 14.5-18.5 g/dl 13.3 g/dl

Ht (%) 45-56 % 39 %
Leukocyte (103/l) 9.4- 34 x 103/mm3 9.100
Thrombocyte (103/l) 192-290 x 103 /μL 210.000
Diff Count * 0-1/1-6/50-70/20-40/2-8 (%) 0/0/62/33/5
ESR (mm/hour) 0-10 mm/hour 2
CRP (mg/dl) 0-0.5 mg/dL <5
I/T ratio <0.2 0.08
*basophil/eosinophil/band/segmen/limphocyte/monocyte.

SUMMARY
A baby boy was born by spontaneous delivery from a G3P2A0 mother, 39 weeks of
gestation, birth weight 3000 grams, body length 49 cm, and head circumference 35
cm.There were no risk factor for intrauterine infection from the mother. APGAR score was
8/9.
When the baby was 12 days old, around nodules,vesicles appeared on his thigh filled with
clear fluid, looking teardrops which later spread to the buttock and then the other areas of
the body, the baby was brought to the physician and was given paracetamol but there was
not improvement. At age 13 days vesicles and papules spread throughout the body and baby
develoved fever but not too high, the temperature was not measured. There was history of
varicella from family, mother and sisters. The mother suffered varicella one day before
delivery. The mother had never got varicella before. The baby brought to ER of MH, and
transferred to the neonatal isolation room.
From phisycal examination there was fever, temperature 37.9 C, baby looked active, and
from dermatologiest status : multiple vesicles like tear drop appearance (+), crusta (+),
Icteric (-), laboratory within normal limit. The baby was given acyclovir and ampicillin

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and gentamisin. At the second day hospitalization, baby had clinical improvement, Some
vesicles had ruptured. The baby was diagnosed as FT-AGA, neonatal varicella and
suspected infection

LISTS OF PROBLEMS
1. A full term baby with appropriate for gestational age (ICD P05.18)
2. Fever
3. Neonatal varicella (ICD B01.89)

WORKING DIAGNOSIS
1. A full-term baby with appropriate for gestational age (ICD P05.18)
2. Neonatal Varicella (ICD B01.89)
3. Suscpected infection (improvement) (ICD Z05.1)

PLANNING
1. A full term baby with appropriate for gestational age
 Diagnosis:anamnesis and phisycal examination
 Therapeutic:
o IVFD : D10 1/5 NS total 300 ml/24 hour 12.5 ml/hour
o Formula milk 8 x 40 ml
 Monitoring : vital sign, body weight, adequate nutrition
 Education : explain about adequate nutrition, and increased of body weight

2. Neonatal Varicella
 Diagnosis:
o PCR  not available
 Therapeutic:

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 o Acyclovir 3 x 50 mg (drip in 1 hour + Nacl 0.9 % 10 cc)
 Monitoring : vital sign, symptom of complication, and change of lession
 Education:
o Explain to the parents that the neonate was suffering from varicella, the signs,
and symptoms that might happen, the available medication, prognosis and
complication of the disease.
3. Suspect infection
 Diagnosis: laboratorium blood cultured
 Therapeutic:
o Antibiotics : ampisillin 3x 80 mg (iv), gentamicin 2x 8 mg (iv)
o Planning to blood culture
 Monitoring : vital sign, laboratorium
 Education:
o Explain to the parents about the medication, prognosis and complication of the
disease

FOLLOW UP
second day of observation, 3 day of hospitalization, 16 day old
S Some vesicles ruptured, new vesicles (-), crusta (+) hyperpigmentation (+), fever (-),
baby was active

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 O General condition:
Baby was active, No fever.
BW=3000 g.
Diuresis 2mL/kg/hr
Specific Conditions:
Head: Flat fontanel, Conjunctiva anemic (-), sclera icteric (-).
Chest No retraction.
Heart: normal I-II heart sound, murmur (-), gallop (-)
Lung were within normal limits.
Abdomen Flat, liver and spleen unpalpable, normal bowel sounds
Genitalia Testis +/+, phimosis(-)
Extremity warm, capillary refill time <3 seconds
Dermatologist status vesicles (+), crusta(+), hyperpigmentation (+)

A 1.A full-term baby with appropriate for gestational age (ICD P05.18)
2.Neonatal Varicella (improvement ) (ICD B01.89)
3.Suscpected infection (improvement) (ICD Z05.1)

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 P  Ampisillin 3 x 80 mg (iv) ( day 3)
 Gentamicin 2x 8 mg (iv) ( day 3)
 Acyclovir 3x 50 mg (iv)(drip in 1 hour + Nacl 0.9 % 10 cc) ( day 3)
 Formula milk 8 x 80 mL (via oral ) (200 ml/kg/day)

Peroral Total
Carbohydrat 6,7g/100ml
42.88 g=171.52 kcal
Protein 1.3g/100ml
8.32 g =33.28 kcal
Fats 3.0g/100ml
19.2 g =172.8 kcal
Total calories 377.6 kcal/day 377.6 kcal/day
125.8 kcal/kg/day

3th day observation, fourthday of hospitalization, 17 days old

S The baby was showed better progress, active , almost vesicles was ruptured and
dried, crusta (+), hyperpigmentation (+)
O General condition:
Active, good sucking reflex , no fever
Other vital signs were within normal limits.
BW=3000 g.
Diuresis: 2.1 mL/kg/hr
Specific Conditions:
Head: Flat fontanel, anemic conjunctiva (-),icteric sclera (-).
Chest No retraction.
Heart: normal I-II heart sound, murmur (-), gallop (-)
Lung were within normal limits.
Abdomen Flat, liver and spleen unpalpable, normal bowel sounds
Genitalia Testis +/+ , fimosis (-)
Extremity warm, capillary refill time <3 seconds

Dermatologist status: almost vesicles are ruptured and dried, crusta (+),
hyperpigmentation (-)

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 A 1.A full-term baby with appropriate for gestational age (ICD P05.18)
2.Neonatal Varicella (improvement ) (ICD B01.89)
3.Suscpected infection (improvement) (ICD Z05.1)
P
 Acyclovir 3 x 50 mg (drip in 1 hour + Nacl 0.9 % 10 cc) (iv) (day 4)
 Ampisillin 3x 80 mg (iv) (day 4)
 Gentamisin 2x 8 mg (iv) (day 4)
 Formula milk 8 x 80 mL (via oral ) (200 ml/kg/day)

Peroral Total
Carbohydrat 6,7g/100ml
42.88 g=171.52 kcal
Protein 1.3g/100ml
8.32 g =33.28 kcal
Fats 3.0g/100ml
19.2 g =172.8 kcal
Total calories 377.6 kcal/day 377.6 kcal/day
125.8 kcal/kg/day

Day 4 of day observation, fifth day of hospitalization, 17 day old

S The baby was active, no fever(-), almost of vesicle are dried
O General condition:
Active , good sucking reflex, no fever
Other vital signs were within normal limits.
BW: 3050 g
Diuresis: 1.8 ml/kg/hr
Specific Conditions:
Head: Flat fontanel, anemic conjunctiva (-),icteric sclera (-).

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 Chest No retraction.
Heart: normal I-II heart sound,murmur(-) gallop (-)
Lung were within normal limits.
Abdomen Flat, liver and spleen unpalpable, normal bowel sounds
Genitalia Testis +/+ , fimosis (-)
Extremity warm, capillary refill time <3 seconds
Dermatologies status : almost vesicles throughout the body are ruptured and dried,
crusta (+),
hyperpigmentation (-)
A 1.A full-term baby with appropriate for gestational age (ICD P05.18)
2.Neonatal Varicella (improvement ) (ICD B01.89)
3.Suscpected infection (improvement) (ICD Z05.1)
P  Acyclovir 3 x 50 mg (iv) (drip with Nacl 0.9 % in one hour) ( day 5)
 Ampisillin 3x 80 mg (iv) (day 5) stopped
 Gentamisin 2x 8 mg (iv) (day 5) stopped
 Formula milk 8 x 80 mL (via oral) (200 ml/kg/day)

Peroral Total
Carbohydrat 6,7g/100ml
42.88 g=171.52
kcal
Protein 1.3g/100ml
8.32 g =33.28 kcal
Fats 3.0g/100ml
19.2 g =172.8 kcal
Total calories 377.6 kcal/day 377.6 kcal/day
125.8 kcal/kg/day

5 th day observation, sixth day of hospitalization, 18 day old

S The baby was active, no fever (-), all of vesicle are dried
O General condition:
Active , good sucking reflex, no fever

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 Other vital signs were within normal limits.
BW: 3100 g
Diuresis: 1.8 ml/kg/hr
Specific Conditions:
Head: Flat fontanel, anemic conjunctiva (-),icteric sclera (-).
Chest No retraction.
Heart: normal I-II heart sound,murmur(-) gallop (-)
Lung were within normal limits.
Abdomen Flat, liver and spleen unpalpable, normal bowel sounds
Genitalia Testis +/+ , fimosis (-)
Extremity warm, capillary refill time <3 seconds
Dermatologies status : almost all vesicles all of body had ruptured and dried, crusta
(+), hyperpigmentation (-)
A 1.A full-term baby with appropriate for gestational age (ICD P05.18)
2.Neonatal Varicella (improvement ) (ICD B01.89)
P  Acyclovir 3 x 50 mg (iv) (drip with Nacl 0.9 % in one hour) (day 6)
 Formula milk 8 x 80 mL (via oral) (200 ml/kg/day)
Peroral Total
Carbohydrat 6,7g/100ml
42.88 g=171.52
kcal
Protein 1.3g/100ml
8.32 g =33.28 kcal
Fats 3.0g/100ml
19.2 g =172.8 kcal
Total calories 377.6 kcal/day 377.6 kcal/day
125.8 kcal/kg/day

6 th day observation, seventh day of hospitalization, 19 day old

S The baby was active, no fever(-), all of vesicles are dried
O General condition:
Active , good sucking reflex, no fever
Other vital signs were within normal limits.
BW: 3100 g

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 Diuresis: 1.9 ml/kg/hr
Specific Conditions:
Head: Flat fontanel, anemic conjunctiva (-),icteric sclera (-).
Chest No retraction.
Heart: normal I-II heart sound,murmur(-) gallop (-)
Lung were within normal limits.
Abdomen Flat, liver and spleen unpalpable, normal bowel sounds
Genitalia Testis +/+ , fimosis (-)
Extremity warm, capillary refill time <3 seconds
Dermatologies status : almost vesicles all of body are ruptured and dried, crusta
(+), hyperpigmentation (-)
A 1.A full-term baby with appropriate for gestational age (ICD P05.18)
2.Neonatal Varicella (improvement ) (ICD B01.89)
P  Acyclovir 3 x 50 mg (iv) (drip with Nacl 0.9 % in one hour) ( day 7)
 Formula milk 8 x 80 mL (via oral) (200 ml/kg/day)
Peroral Total
Carbohydrat 6,7g/100ml
42.88 g=171.52
kcal
Protein 1.3g/100ml
8.32 g =33.28 kcal
Fats 3.0g/100ml
19.2 g =172.8 kcal
Total calories 377.6 kcal/day 377.6 kcal/day
125.8 kcal/kg/day

PROGNOSIS
1. Quo ad vitam : dubia ad bonam
2. Quo ad functionam : dubia ad bonam
3. Quo ad sanationam : dubia ad bonam

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DISCUSSIONS
A 14 days old baby boy was born from a G3P2A0 mother at 39 weeks of gestational age,
his birth weight was 3000 grams. He was born without any evidence of intrauterine
infection. There was a history varicesella in family (mother and sister). The baby was born
from mother with varisella.When he was 12 days old, nodules and vesicles filled with clear
fluid, shaped like teardrops, beganning appearing in his body. Baby was brought to
physsician and was given paracetamol but there was no improvement. At 13 days, vesicles
had spread throughout the body and baby had fever but not too high , the temperature is not
measured. The mother had varicella one day before delivery. We diagnosed the baby with
neonatal varicella.

Neonatal varicella caused by Varicella zoster virus (VZV) is a viral infection that can result
in varicella (chickenpox), zoster, and fetal injury. Clinicians who care for neonates can
encounter VZV in multiple different scenarios, including neonates born to mothers with
primary varicella, neonates exposed to a contact with an active infection, neonates with
congenital malformations, or neonates who develop a vesicular rash after birthamong
newborns. 1Chickenpox is an acute febrile illness with vesiculo-papular rash caused by
varicella-zostervirus (VZV). Its manifestation varies from mild febrile illness to severe life-
threatening complications like bacterial super-infection, pneumonia, encephalitis and
bleeding disorders. Disease severity and mortality rate (as high as 30% without antiviral
treatment) is particularly high in neonates especially if they have not received passive
immunity from their mother. 2

The diagnosis of varicella infection is primarily based on the signs and symptoms.
Confirmation is by examination of the fluid within the vesicles, scraping of lesions that
have not crusted or byblood for evidence of an acute immunologic response. Polymerase
chain reaction (PCR) has the highest yield and can be utilized for non-skin samples such as

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bronchoalveolar lavage sample and cerebrospinal fluid. Direct fluorescent antibody testing
has largely replaced the Tzanck test.The vesicular fluid can also be cultured, but the yield is
low compared to PCR. Blood tests areused to identify a response to acute infection (IgM),
previous infection, and subsequent immunity (IgG).1,3 But this laboratory test for PCR is
not available in our hospital.

Pregnant women who develop varicella can transmit the virus to their fetus when they
become viremic. Primary varicella infection in the first 2 trimesters of pregnancy (highest
risk at 8–20 weeks) can result in fetal death or congenital varicella syndrome. The latter,
which occurs in approximately 2% of fetuses exposed to VZV during this time of
pregnancy, is characterized by limb hypoplasia, cutaneous lesions in a dermatomal
distribution, eye and skeletal abnormalities, and neurologic defects. Neonates born to
women who develop varicella within 21 days of delivery are at risk for congenital varicella
disease. One study found the attack rate for neonates born to mothers with varicella this late
in pregnancy to be 24%. Neonates born to mothers who develop clinical evidence of
varicella from 5 days before to 2 days after delivery have a higher case fatality rate. This
higher fatality rate is due to inadequate maternal antibody production and transfer to the
neonate at the time of birth. When maternal infection occurs more than 5 days before
delivery and the pregnancy is of more than 28 weeks’ gestation, maternal transplacental
immunoglobulin (Ig) G can decrease the severity of disease. Neonates with congenital
varicella disease can have a severe clinical course, with significant morbidity and mortality.
In the pre-antiviral era, the mortality rate for these infants was as high as 31%, with the
greatest risk being to neonates born to women who develop a rash within 4 days of
delivery. 1,2

This baby we diagnosed with neonatal variscella. The baby was born from mother with
varicella one day before delivery. Neonates exposed to a contact with varicella after birth
develop a rash no earlier than 10 days after delivery. In contrast to neonates born to mothers

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with primary varicella infection, those neonates who acquire the virus after birth tend to
have a milder clinical course. Exceptions to this finding are neonates born to mothers
without VZV immunity, as well as those that are born premature (see section on varicella
zoster Ig use recommendations). Acquired in utero late in third trimester or in the first few
days ost partum. Infant presents with centripetal rash similar to postnatal rash in the first
10-12 days of life. 4,5

Clinical presentation is variable , from skin, A sentripetal rash (beginning on the trunk and
spreading to the face and scalp , sparing the extremities) begin as red maules and progresses
to vesicles and encrustation. Lesion are more common in the diaper area and skin folds.
management therapy Isolation precaution for all infectious diseases , including maternal
and neonatal precaution, treatment for neonatal and mothers who develop VZV infection
(rash) within 5 days before 2 days after delivery should receive 125 U of VariZIG as soon
as possible and not later than 10 days. Intravenous immunoglobulin (IVIG) (400 mg/kg)
should be used if variZIG not available. Prophylactic administration of oral acyclovir
beginning 7 days after exposure also may prevent or attenuate varisella disease in exposed
infants., if maternal rash occurring > 7 days before delivery. But in this case the infants
don’t accept profilaksis before.Acyclovir therapy 15 mg/kg/dose every 8 hours for 7 days
should be considered for post exposure profilaksis as well as treatment in symptomatic
neonates.The present study suggest tha the combination of IVIG administered to the
defined risk neonates soon after birth or post natal contact and acyclovir given
intravenously starting from 7 days after the onset of maternal rash can be effectively
prevent clinical perinatal varicella. Further studies should be conducted to evaluate whether
acyclovir prophylaxis alone would be effective.It is also necessary to keep the baby warm,
give adequate nutritionand maintenance fluid requirements. (level of evidence I)4,5,6

There were fever two day after the baby had varicella, we assested with suspected
infectious can caused from secondary infection. Suspected infectious in this patient may be

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caused by secondary bacterial infection due to the skin lesion. Secondary bacterial infection
is the most common complication in neonatal varicella usually caused by streptococci or
staphylococci. Skin infection may lead to severe sequeale such as toxic shock syndrome
and necrotizing fasciitis. Septicemia was observed in 0.5 % of 2534 case seen at the Willard
Parker Hospital from 1929 to 1934. Central nervous system complications, which are
uncommon, include encephalitis, cerebellar ataxia, aseptic meningitis and myelitis,
glomerulonephritis and arthritis have also been report. Primary varicella pneumonia is
dreaded complication of chickenpox and responsible for most fatalities. It is most common
in immunocompromised patients, in adults and in most fatal cases of neonatal chickenpox.
The onset of pneumonia occurs generally 2 to 4 days but sometimes as long as days after
the appearance of the exanthema.The patient was treated with antibiotic ampicillin dan
gentamicin for 5 days. The result of repeat laboratory was normal.
In addition to the antibiotics, nutritional support was also given to the patient. According to
literature a newborn requires at least 50-60 cal/kg/day of energy to maintain weight, but in
order to achieve weight gain, the newborn should be given 100-120 calories/kg/day.7,8
During hospitalization, monitoring of nutrient intake revealed adequate daily calorie intake
per day appropriate to requirement.
The body weight from day 1 to day 7 of treatment was 3,000; 3,000; 3,050; 3,100; 3,100;
and 3,150 grams consecutively. During one week of observation, the patient's weight gain
increased with an average increase of 30-50g/day. Growth assessment is a part of early
detection of clinical and monitoring conditions in infants. Also, monitoring growth and plot
in to an age-appropriate growth curves. Currently, the most commonly used curves WHO’s
2006 curve.

At the 7thday of treatment, from the physical examination the infants showed improvement.
The baby was planned to have growth and development monitoring monthly. The growth
monitoring should use WHO curves, with expected weight gain of 30 grams/ day.

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Developmental progress can be monitored by Denver II. The parent was educated about the
complication from diseased, possibility of growth and/ or developmental disorder that may
occur.The parent was also taught about the importance of regular monitoring, detection,
and early intervention. Immunization also need to be given as per infant's age. The parent
also was the benefits and the importance of immunization. 9

Death among neonates caused by postnatally acquired disease are very rare. There are
dataindicating an appreciably higher incidence of complication or death in neonates than in
older childer. Preblud and associates found that of 92 reported deaths caused by varicella
from 1968 to 1978 in children younger than 1 year of age, only 5 occurred in newborns
( age 8 hour to 19 days). Although mortality was increased by factor of 4 in infant younger
than 1 year of age compared with older children, there was low calculated death rate for
varicella throughout childhood (8 in 100.000 patients if younger than 1 year old and 2 in
100.000 patients aged 1 to 14 years). The child survived; ACV was administered for 10
days. The only other report in the English literature of severe postnatally acquired varicella
in an infant youger than 1 month old is that of Gustafson and colleagues. 8

REFERENCES

1. Petersen R, Miller AS. Varicella Zoster Virus Infection in Neonates.NeoReviews

2016;17;e507
2. Sharma P, Jora R, Purohit A, Garg A, Laxminarayan. Neonatal Varicella. Indian
Journal of Clinical Practice. 2013. Vol 4 No.5
3. Ayoade F, Gossman WG. Varicella (Chickenpox), Zoster. NCBI Bookshelf. 2018; 1-5.
4. Biskupska M,MałeckaI,Stryczyńska-KazubskaJ,WysockiJ.Varicella — a potential
threat to maternal and fetal health. Ginekologia Polska. 2017; 88, 1: 13–19

National Board Examination,Jakarta, 5th-6thMay 2018 Page 21

5. Gomella TL. Neonatology: management, procedures, on-call problems, diseases and
drugs. 7. ed. New York: McGraw-Hill Med, 2013.
6. Huang YC, Lin TY, Lin YJ, Lien RI, Chou YH. Prophylaxis of intravenous
immunoglobulin and acyclovir in perinatal varicella. Eur J Pediatr. 2001;160:91-94.
7. Kadim M, Roeslani R, Nurmalia L. Konsensus IDAI : Asuhan nutrisi pada bayi
prematur. Jakarta: Badan penerbit IDAI, 2016.
8. Gerson AA. Chickenpox, measles, and mumps. in Remington and Klein (ed).
infectious disease of the fetus and newborn infant Fifth edition. USA: WB Saunders
Company. 2001. P : 683-732
9. Ben XM. Nutritional management of newborn infants : Practical guidelines. World J
Gastroenterol. 2008;14(40) : 6133-6139.

References of Level of Evidence

1. Petersen R, Miller AS. Varicella Zoster Virus Infection in Neonates.Neo Reviews

2016;17;e507. (Level of Evidence III)
2. Sharma P, Jora R, Purohit A, Garg A, Laxminarayan. Neonatal Varicella. Indian
Journal of Clinical Practice. 2013. Vol 4 No.5. (Level of Evidence III)

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3. Huang YC, Lin TY, Lin YJ, Lien RI, Chou YH. Prophylaxis of intravenous
immunoglobulin and acyclovir in perinatal varicella. Eur J Pediatr. 2001;160:91-94.
(Level of Evidence I)
4. Biskupska M,MałeckaI,Stryczyńska-KazubskaJ,WysockiJ.Varicella — a potential threat
to maternal and fetal health. Ginekologia Polska. 2017; 88, 1: 13–19 (level of evidence
III)

LIST OF ABBREVIATIONS

FT-AGA : Full Term - Appropriate for Gestational Age

IVIG : Intravenous Immunoglobulin
PCR : Polymerase chain reaction
VZV : Varicella zoster virus

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ANNEXES
Annex 1. Patient’s Growth Chart

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