VARICELLA & HERPES

ZOSTER
Two diseases with different clinical manifestation
but caused by same virus
Etiology : Varicella-Zoster virus (VZV)
Family : Herpes virus
Primary infection Varicella (Chickenpox)
virus can remains latent in sensory ganglia
Herpes zoster : represents as reactivation of
this latent virus

VARICELLA (chickenpox; cacar air)

EPIDEMIOLOGY
can occur in all ages, including newborn
90% less than 10 years old; peak 5-9 year
transmission : direct contact & droplets
infectious virus inside of vesicles, but not
in crusts
contagious period : 24 hours before rash
until all become crusts, usually 7 8 days

VARICELLA (chickenpox; cacar air)

CLINICAL MANIFESTATION
Incubation period : 11-21 (13-17 days)
Prodromal stage :
24 hours before rash appears
mild fever, malaise, anorexia
Rash: macules-red papule vesicle crusts
mostly in trunk, expands to face and head
small parts of distal extremity

CLINICAL MANIFESTATION (contd)

Typical feature: at the peak of disease

all types of rash can occur in one time
vesicles occur also in oral mucous ( as
ulcer), genital, conjunctiva, cornea, larynx
generalized lymphadenopathy can occur
Neonatal varicella : occur in neonates
born to mothers who develop varicella
5 days before and 2 days after delivery

VARICELLA (chickenpox; cacar air)

DIAGNOSIS
Anamnesis : - symptoms
- history of exposure
Examination: - sign of typical rash
Laboratory : - leukocyte count normal or low
- giant-multinucleated cell on
smear from base of vesicle
- virus isolation in tissue culture

VARICELLA (chickenpox; cacar air)

COMPLICATION
most common: 2nd bacterial skin infection
Thrombocytopenia : cause hemorrhage
Pneumonia : seldom in childhood
Laryngitis : cause respiratory distress
Myocarditis, pericarditis, endocarditis
Hepatitis
Glomerulonephritis

COMPLICATION (contd)
Keratitis, conjunctivitis
Arthritis
Encephalitis
Congenital varicella occur if pregnant
women had varicella in 1st trimester:
low birth weight , cicatricial skin lesions
(keloid), muscle atrophy, chorioretinitis,
convulsions, mental retardation

VARICELLA (chickenpox; cacar air)

PREVENTION
Active immunization :
Live attenuated virus vaccine
Passive immnunization ;
Varicella Zoster Immunoglobulin (VZIG)
dose : 125 unit/ 10 kg BW, effective if
administered within 72 hours after exposure
Zoster Immunoglobulin (ZIG): 2 5 ml i.m.

VARICELLA (chickenpox; cacar air)

TREATMENT
Symptomatic :
- Antipyretic :
precaution: aspirin can cause Reye syndrome
- Itchy : powder, lotion
- Sedatives
Acyclovir

VARICELLA (chickenpox; cacar air)

PROGNOSIS
Usually good prognosis
Bad prognosis associated with complication

HERPES ZOSTER
EPIDEMIOLOGY
Usually occur in adulthood, 5% in < 15 year
no difference in race, sex and season period
history of had varicella in the past or if not
may be ever had mild / sub-clinical disease
Reactivation can cause by repeated VZV
infection, physical trauma, X-ray therapy,
immunosuppressive drugs, malignancy

HERPES ZOSTER
PATHOGENESIS
Not fully understood
similar as recurrence of herpes simplex
virus infection
theory: during varicella infection, VZV from
skin or mucous membrane through
peripheric sensory nerves, centripetally go
to posterior or cranial nerve ganglion

PATHOGENESIS (contd)

What happen in latency ?

1. Dynamic states : virus had multiplied in
nerve, but in very slow growth
2. Static states : material genetic of virus
present in nerve without cause infection
Two theories of intermittently reccurrences
1. Ganglion trigger theory
2. Skin trigger theory

HERPES ZOSTER
CLINICAL MANIFESTATION
Incubation period : 7 12 days
early symptoms: fever and neuralgic/
burning pain along involved dermatome
Skin lesions have different size
firstly erytheme macule -> papule -> vesicle
-> confluence to form bulla

CLINICAL MANIFESTATION (contd)

Vesicle absorbed -> crust -> scabbing ->

brown macule -> gradually disappear
typical feature of lesion :
Vesicles grouping as Crop along dermatome
pain sensation, mostly unilateral
usually with regional lymphedenopathy
Location : Thoracal (55%), cranial (20%),
Lumbal (15%), sacral (5%)

HERPES ZOSTER
COMPLICATION
Post herpetic neuralgia
- incidence 10- 15%, seldom in childhood
- occur some weeks or months after skin
lesions disappeared
- common after Herpes Zoster Opthalmicus
(with other complications: keratitis,uveitis,
scleritis, chorioretinitis and optic neuritis)

COMPLICATION (contd)

Motor paralysis :
- incidence 1- 5%
- occur 2 weeks after skin eruption appear
- usually in muscle which innervated
across-side with involved dermatome
Meningoencephalitis
- incidence : 0.2 0.5 %
- occur during, before or after skin eruption
- most common in Cranial herpes zoster
and immunocompromized patients

HERPES ZOSTER
DIAGNOSIS
Anamnesis:
- history of varicella in the past
- exposure to varicella or herpes zoster
- Prodromal symptoms : fever and pain
Examination :
- Typical skin lesion
- regional lymphedenopathy

DIAGNOSIS (contd)

Laboratory :
- Tzanck smear : multinucleated giant cell
and typical epithelial cell with acidophilic
intranuclear inclusion bodies
* similar as herpes simplex virus (HSV)
- Virus isolation, differentiating both viruses
* VZV : local cytopathigenic effect
* HSV : diffuse cytopathogenic effect

HERPES ZOSTER
TREATMENT
Symptomatic
- Bed rest, analgesic
Topical antiseptic
2nd infection : topical / systemic antibiotics
Acyclovir
Systemic corticosteroid (prednison): acute
phase, particularly in adult with severe pain

HERPES ZOSTER
PREVENTION
Passive and active immunization
Susceptible and high risk person must be
protected to contact with herpes zoster
patients
PROGNOSIS
Normal individual : self limited disease
Bad prognosis in immunocompromized ones

VARIOLA (smallpox; cacar)

INTRODUCTION
Contagious infection disease caused by
Variola virus
WHO: Intensive eradication program
- 1967 : > 30 endemic countries
- 1975 :

5 countries; 1977 :

- 1979 :

zero country

2 countries

- 1980 : declaration of free from variola

VARIOLA (smallpox; cacar)

ETIOLOGY
Genus orthopox virus
found in respiratory tract secrets and
in vesicle of skin lesion
can live long (months) in dry crust
spreading by airborne transmission
infectious period: from the end of incubation
period and during all stages of disease

VARIOLA (smallpox; cacar)

EPIDEMIOLOGY
All person are susceptible, except ones
who ever had variola or cowpox or
vaccinia
Seasonal : particularly at the end of winter
and during spring

VARIOLA (smallpox; cacar)

PATHOLOGY
Involving skin and mucous membrane
extending deeper into skin and mucous
membrane with changes of skin lesion
macule -> papule -> vesicle -> pustule ->
crust.
2nd bacterial infection commonly occur and
hemorrhage also can occur

VARIOLA (smallpox; cacar)

CLINICAL MANIFESTATION
Incubation period : 7 17 days
Prodromal period : 2 4 days
- fever, cephalgia, malaise, myalgia, nausea,
vomiting, abdominal pain
Skin eruption:
- after prodromal period (4 days), fever subside
and typical skin lesion appear

CLINICAL MANIFESTATION (contd)

Distribution : particularly face and extremity

Only one stage of skin lesion in one period
Firstly : macule and papule
- 3rd 4th day : vesicle
- 6th day : changes to umbilicated pustule
- 10th day : changes to crust for another days
and scabbing with cicatrix

CLINICAL MANIFESTATION (contd)

Severe manifestation : hemorrhagic type

- incidence 2 3 %
- mortality rate nearly 100%
- hemorrhage can occur since at prodromal
period from various part of body
- death usually occur in 1st week of disease
less severe : variola minor or alastrim
- caused by less pathogenic variola virus

VARIOLA (smallpox; cacar)

COMPLICATION
Hemorrhagic manifestation
2nd bacterial infection :
- impetigo
- pneumonia
- empyema
- acute otitis media

VARIOLA (smallpox; cacar)

DIFFERENTIAL DIAGNOSIS
Varicella, particularly with variola minor
- distribution of skin lesion
- feature of skin lesion in one period
- vesicle not umbilicated
- vesicle : uniloculus
Generalized vaccinia or Excema vaccinatum
Impetigo, Scabies, Erytema multiforme

VARIOLA (smallpox; cacar)

DIAGNOSIS
Anamnesis : - symptoms
- contact /exposure
- vaccination history
Examination : typical skin manifestation
Laboratory: - electron micrascopy
- serologic test
- virus isolation

VARIOLA (smallpox; cacar)

TREATMENT
No effective antiviral available
Supportive and symptomatic
Convalescent Smallpox Serum and
Vaccinia Immune Globuline ??

VARIOLA (smallpox; cacar)

PREVENTION
Active immunization: variola vaccine
- most effective World free from Variola
Passive immunization:
- vaccinia immune globulin