Chickenpox (varicella) dr harivansh chopra

ChickenpoxChickenpox
(Varicella)(Varicella)
Dr. Harivansh ChopraDr. Harivansh Chopra
DCH, MDDCH, MD
PROFESSORPROFESSOR
Department of Community Medicine,Department of Community Medicine,
LLRM Medical College, Meerut.LLRM Medical College, Meerut.
harichop@gmail.comharichop@gmail.com
11/07/1711/07/17 11

ObjectivesObjectives
1.1. To study the epidemiology of Chickenpox.To study the epidemiology of Chickenpox.
2.2. To study the differential diagnosis andTo study the differential diagnosis and
treatment of the disease.treatment of the disease.
3.3. To study the prevention of Chickenpox.To study the prevention of Chickenpox.
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Chickenpox (Varicella)Chickenpox (Varicella)
1.1. It is characterised byIt is characterised by
vesicular rash thatvesicular rash that
may be accompaniedmay be accompanied
by fever and malaise.by fever and malaise.
2.2. It is worldwide inIt is worldwide in
distribution and occursdistribution and occurs
in both epidemic andin both epidemic and
endemic forms.endemic forms.
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AgentAgent
1.1. The causative agent of chickenpox, V-Z virusThe causative agent of chickenpox, V-Z virus
is also called “Human (alpha) herpes virusis also called “Human (alpha) herpes virus
3”.3”.
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AgentAgent
2.2. Varicella-zoster virus (VZV)Varicella-zoster virus (VZV)
causes primary, latent, andcauses primary, latent, and
recurrent infections.recurrent infections.
3.3. The primary infection isThe primary infection is
manifested as Varicellamanifested as Varicella
(chickenpox) and results in(chickenpox) and results in
establishment of a lifelongestablishment of a lifelong
latent infection of sensorylatent infection of sensory
ganglion neurons.ganglion neurons.
Microscopic view of sensory
ganglion neurons: Common
site of latent infection by Varicella
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AgentAgent
4.4. Reactivation of theReactivation of the
latent infectionlatent infection
causes Herpes Zostercauses Herpes Zoster
(shingles).(shingles).
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Herpes ZosterHerpes Zoster
1.1. Reactivation of VaricellaReactivation of Varicella
zoster virus.zoster virus.
2.2. Associated with:Associated with:
1.1. Aging.Aging.
2.2. Immunosuppression.Immunosuppression.
3.3. Intrauterine exposure.Intrauterine exposure.
4.4. Varicella at < 18 months ofVaricella at < 18 months of
age.age.
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Source of InfectionSource of Infection
1.1. Usually a case of chickenpox.Usually a case of chickenpox.
2.2. The virus occurs in theThe virus occurs in the
oropharyngeal secretionsoropharyngeal secretions
and lesions of skin andand lesions of skin and
mucosa.mucosa.
3.3. Rarely the source of infectionRarely the source of infection
may be a patient with Herpesmay be a patient with Herpes
Zoster.Zoster.
Chickenpox transmission occurs
mainly from the oropharyngeal
secretions of a case.
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InfectivityInfectivity
The period ofThe period of
communicability ofcommunicability of
patients with Varicella ispatients with Varicella is
estimated to range from 1estimated to range from 1
to 2 days before theto 2 days before the
appearance of rash, and 4appearance of rash, and 4
to 5 days thereafter.to 5 days thereafter.
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Incubation periodIncubation period
Usually 14 to 16 days,Usually 14 to 16 days,
although extremes asalthough extremes as
wide as 7 to 21 dayswide as 7 to 21 days
have been reported.have been reported.
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AgeAge
1.1. Chickenpox occursChickenpox occurs
primarily amongprimarily among
children under 10children under 10
years of age.years of age.
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ImmunityImmunity
1.1. One attack givesOne attack gives
durable immunity.durable immunity.
Second attacks areSecond attacks are
rare.rare.
2.2. The acquisition ofThe acquisition of
maternal antibodymaternal antibody
protects the infantprotects the infant
during the first fewduring the first few
months of life.months of life. Hemorrhagic Varicella in infant :
One attack of Varicella
gives durable immunity.11/07/1711/07/17 1212

ImmunityImmunity
3.3. The IgG antibodies persist forThe IgG antibodies persist for
life and their presence islife and their presence is
correlated with protectioncorrelated with protection
against Varicella.against Varicella.
4.4. The cell- mediated immunityThe cell- mediated immunity
appears to be important inappears to be important in
recovery from V -Z infectionsrecovery from V -Z infections
and in protection against theand in protection against the
reactivation of latent V-Zreactivation of latent V-Z
virus.virus.
Structure of an IgG antibody:
Antibody against Varicella is
protective
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Pregnancy & VaricellaPregnancy & Varicella
Infection duringInfection during
pregnancy presents apregnancy presents a
risk for the fetus and therisk for the fetus and the
neonate.neonate.
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Environmental FactorsEnvironmental Factors
1.1. Chickenpox shows aChickenpox shows a
seasonal trend in India, theseasonal trend in India, the
disease occurring mostlydisease occurring mostly
during the first six monthsduring the first six months
of the year.of the year.
2.2. Overcrowding favours itsOvercrowding favours its
transmission.transmission.
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TransmissionTransmission
1.1. Chickenpox is transmittedChickenpox is transmitted
from person to person byfrom person to person by
droplet infection and bydroplet infection and by
droplet nuclei.droplet nuclei.
2.2. Most patients are infectedMost patients are infected
by "face-to-face" (personal)by "face-to-face" (personal)
contact.contact.
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3.3. The portal of entry ofThe portal of entry of
the virus is thethe virus is the
respiratory tract.respiratory tract.
4.4. Since the virus isSince the virus is
extremely labile, it isextremely labile, it is
unlikely that fomitesunlikely that fomites
play a significant roleplay a significant role
in its transmission.in its transmission.
Main portal of chickenpox
transmission is respiratory
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SECONDARY ATTACK RATE
90%11/07/1711/07/17 1818

5.5. Contact infectionContact infection
undoubtedly plays a roleundoubtedly plays a role
when an individual withwhen an individual with
Herpes Zoster is an indexHerpes Zoster is an index
case.case.
6.6. The virus can cross theThe virus can cross the
placental barrier and infectplacental barrier and infect
the foetus, a conditionthe foetus, a condition
known as Congenitalknown as Congenital
Varicella.Varicella.
Mother-to-Child transmission of
Varicella can cause Congenital Varicella
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Congenital Varicella SyndromeCongenital Varicella Syndrome
1.1. Results fromResults from
maternal infectionmaternal infection
during pregnancy.during pregnancy.
2.2. Period of risk mayPeriod of risk may
extend through firstextend through first
20 weeks of20 weeks of
pregnancy.pregnancy.
3.3. Risk appears to beRisk appears to be
small (< 2%).small (< 2%).
MRI scan of foetus in-utero:
Risk of transmission of Varicella
extends through first 20 weeks.
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Congenital Varicella Syndrome –Congenital Varicella Syndrome –
FeaturesFeatures
1.1. Damage to SensoryDamage to Sensory
Nerves :Nerves :
1.1. Cicatricial skinCicatricial skin
lesions.lesions.
2.2. Hypopigmentation.Hypopigmentation.
This neonate suffering from
Congenital Varicella died at
6th
day: Typical skin lesions
seen at autopsied body
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FeaturesFeatures
2.2. Damage to Optic StalkDamage to Optic Stalk
and Lens Vesicle :and Lens Vesicle :
1.1. Microphthalmia.Microphthalmia.
2.2. Cataracts.Cataracts.
3.3. Chorioretinitis.Chorioretinitis.
4.4. Optic atrophy.Optic atrophy.
Fetus with Congenital Varicella
at autopsy (26 weeks). Note the
collapsed cranium, disproportionate
Necrosis of the ocular globes
and flattened midface.
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FeaturesFeatures
3.3. Damage toDamage to
Brain/Encephalitis :Brain/Encephalitis :
1.1. Microcephaly.Microcephaly.
2.2. Hydrocephaly.Hydrocephaly.
3.3. Calcifications.Calcifications.
3.3. Aplasia of brain.Aplasia of brain.
Brain sonograph of a fetus with
Congenital Varicella at 18 weeks.
Note the appearance of the falx cerebri,
choroid plexus and cerebral hemispheres.
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FeaturesFeatures
5.5. Damage to CervicalDamage to Cervical
or Lumbosacralor Lumbosacral
Cord :Cord :
1.1. Hypoplasia of anHypoplasia of an
extremity.extremity.
2.2. Motor and sensoryMotor and sensory
deficits.deficits.
3.3. Absent deep tendonAbsent deep tendon
reflexes.reflexes.
Neonate with Congenital Varicella:
Note hypoplasia of lower extremity.
The extremity had sensory and
motor deficits.11/07/1711/07/17 2424

FeaturesFeatures
5.5. Damage to Cervical orDamage to Cervical or
Lumbosacral Cord :Lumbosacral Cord :
4.4. Anisocoria.Anisocoria.
5.5. Horner syndrome.Horner syndrome.
5.5. Anal/urinary sphincterAnal/urinary sphincter
dysfunction.dysfunction.
Pictoral representation of anisocoria.
(this case is not Congenital Varicella)
Pictoral representation of Horner Syn.
(this case is not Congenital Varicella)
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Anisocoria: Both
pupils are usually of
equal size. If they are
not, that is termed
anisocoria (from "a-",
not + "iso", equal +
"kore", pupil = not
equal pupils)
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The clinical features of Horner's
syndrome can be remembered using
the mnemonic, "HornyPAMELa"
for Ptosis, Anhidrosis, Miosis, Enoph
thalmos and Loss of ciliospinal
reflex.
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Clinical features of Chickenpox –Clinical features of Chickenpox –
The clinical course of chickenpox may beThe clinical course of chickenpox may be
divided into two stages:divided into two stages:
(A)(A)Pre-eruptive Stage.Pre-eruptive Stage.
(B) Eruptive Stage.(B) Eruptive Stage.
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Pre-Eruptive StagePre-Eruptive Stage
1.1. Onset is sudden withOnset is sudden with
mild or moderatemild or moderate
fever, pain in the back,fever, pain in the back,
shivering and malaise.shivering and malaise.
2.2. This stage is veryThis stage is very
brief, lasting about 24brief, lasting about 24
hours.hours.
Pre-eruptive phase in Varicella
is very brief – characterised by
Fever, pain in back, shivering,
and malaise
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Pre-Eruptive StagePre-Eruptive Stage
3.3. In adults, the prodromalIn adults, the prodromal
illness is usually moreillness is usually more
severe and may last forsevere and may last for
2-3 days before the rash2-3 days before the rash
comes out.comes out.
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Eruptive PhaseEruptive Phase
1.1. In children the rash is often the first sign.In children the rash is often the first sign.
2.2. It comes on the day the fever starts.It comes on the day the fever starts.
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Eruptive Phase –Eruptive Phase –
FeverFever
The fever does not runThe fever does not run
high but showshigh but shows
exacerbations with eachexacerbations with each
fresh crop of eruption.fresh crop of eruption.
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1.1. The rash is symmetrical.The rash is symmetrical.
2.2. It first appears on theIt first appears on the
trunk where it istrunk where it is
abundant, and then comesabundant, and then comes
on the face, arms and legson the face, arms and legs
where it is less abundant.where it is less abundant.
Eruptive Phase – RashEruptive Phase – Rash
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3.3. Mucosal surfaces (e.g.Mucosal surfaces (e.g.
buccal, & pharyngealbuccal, & pharyngeal
mucosa) are generallymucosa) are generally
involved.involved.
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4.4. Axilla may beAxilla may be
affected, but palmsaffected, but palms
and soles are usuallyand soles are usually
not affected.not affected.
5.5. The density of theThe density of the
eruption diminisheseruption diminishes
centrifugally.centrifugally.
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Eruptive Phase – Evolution ofEruptive Phase – Evolution of
RashRash
1.1. The rash advances quickly through theThe rash advances quickly through the
stages of macule, papule, vesicle and scab.stages of macule, papule, vesicle and scab.
2.2. In fact, the first to attract attention are oftenIn fact, the first to attract attention are often
the vesicles filled with clear fluid and lookingthe vesicles filled with clear fluid and looking
like "dew-drops" on the skin.like "dew-drops" on the skin.11/07/1711/07/17 3636

Superficial vesicles
Unilocular Vesicles;
Dew-drop like.
Inflammation around vesicles
Evolution of RashEvolution of Rash
3.3. They are superficial,They are superficial,
with easily rupturedwith easily ruptured
walls and surroundedwalls and surrounded
by an area ofby an area of
inflammation.inflammation.
4.4. Usually they are notUsually they are not
umbilicated.umbilicated.
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Evolution of RashEvolution of Rash
5.5. The vesicles may form crusts without goingThe vesicles may form crusts without going
through the pustular stage.through the pustular stage.
6.6. Many of the lesions may abort.Many of the lesions may abort.
7.7. Scabbing begins 4 to 7 days after theScabbing begins 4 to 7 days after the
appearance of rash.appearance of rash.11/07/1711/07/17 3838

A characteristic featureA characteristic feature
of the rash in chickenpoxof the rash in chickenpox
is its “Pleomorphism”,is its “Pleomorphism”,
i.e. all stages of the rashi.e. all stages of the rash
(Papules, Vesicles and(Papules, Vesicles and
Crusts) may be seenCrusts) may be seen
simultaneously at onesimultaneously at one
time, in the same area.time, in the same area.
Pleomorphic RashPleomorphic Rash
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Varicella – Differential DiagnosisVaricella – Differential Diagnosis
1.1. Herpes simplex.Herpes simplex.
2. Enterovirus.2. Enterovirus.
3.3. Staphylococcus aureus.Staphylococcus aureus.
(Bullous impetigo)(Bullous impetigo)
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4.4. Drug reactions.Drug reactions.
5. Contact dermatitis.5. Contact dermatitis.
6.6. Insect bites.Insect bites.
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Severe Varicella was the most commonSevere Varicella was the most common
illness confused with smallpox before theillness confused with smallpox before the
eradication of this disease.eradication of this disease.
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Differences betweenDifferences between
Smallpox and ChickenpoxSmallpox and Chickenpox
During the first day
or two of rash it
may be impossible,
from the rash
alone, to
differentiate
smallpox from
chickenpox.
11/07/1711/07/17 4343

On day 3, the rash
associated with each
of the diseases
continues to look very
similar.
11/07/1711/07/17 4444

 By day 5, all of the smallpox
lesions are at the same stage
of development.
 However, the patient with
chickenpox shows several
different stages of rash –
There are papules, vesicles
and pustules present.
11/07/1711/07/17 4545

 The smallpox lesions are
large : 5 – 10 mm in size;
firm and deeply embedded
in skin.
 Most of the chickenpox
lesions are smaller : 1 – 5
mm in size; lesions are much
superficial.
11/07/1711/07/17 4646

 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 seperated.
11/07/1711/07/17 4747

 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).
11/07/1711/07/17 4848

Chickenpox – many
pocks on back but very
few on arms or hands.
Smallpox – pocks are
more dense on the arms
and legs than on the
trunk.
11/07/1711/07/17 4949

 In chickenpox there may
be few or no lesions on the
palms of the hands.
 In smallpox, pocks are
usually present on palms
of hands.
11/07/1711/07/17 5050

 In smallpox, many
lesions are present on
the soles of feet.
 In chickenpox, patient
may have very few or no
lesions on soles of feet.
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 In smallpox, death
occured 1 in 10 cases.
 In chickenpox, death is
very uncommon.
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Varicella ComplicationsVaricella Complications
1.1. Secondary bacterialSecondary bacterial
infection of lesions.infection of lesions.
2.2. Cellulitis,Cellulitis,
Lymphadenitis, andLymphadenitis, and
Subcutaneous abscess.Subcutaneous abscess.
3.3. Varicella gangrenosaVaricella gangrenosa
fromfrom S.pyogenesS.pyogenes – a– a
life-threateninglife-threatening
infection.infection.
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4.4. Bacteremia causingBacteremia causing
pneumonia, arthritis,pneumonia, arthritis,
and osteomyelitis.and osteomyelitis.
5.5. CNS manifestations –CNS manifestations –
Encephalitis &Encephalitis &
Cerebellar ataxia.Cerebellar ataxia.
6.6. Varicella hepatitis.Varicella hepatitis.
11/07/1711/07/17 5454

7.7. Acute thrombocytopenia, accompanied byAcute thrombocytopenia, accompanied by
petechiae, purpura, hemorrhagic vesicles,petechiae, purpura, hemorrhagic vesicles,
hematuria, and GI bleeding.hematuria, and GI bleeding.
8.8. Nephritis, Nephrotic syndrome, and HUS.Nephritis, Nephrotic syndrome, and HUS.
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Groups at Increased Risk ofGroups at Increased Risk of
Complications of VaricellaComplications of Varicella
1.1. Healthy adolescents & adults.Healthy adolescents & adults.
2.2. Immunocompromised persons.Immunocompromised persons.
3.3. Pregnant women.Pregnant women.
11/07/1711/07/17 5656

Groups at Increased Risk ofGroups at Increased Risk of
Complications of VaricellaComplications of Varicella
4.4. Newborns of mothersNewborns of mothers
with rash onset within 5with rash onset within 5
days before delivery todays before delivery to
48 hours after delivery.48 hours after delivery.
5.5. Children withChildren with
malignancy ifmalignancy if
chemotherapy waschemotherapy was
given during the I.P.given during the I.P.
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Laboratory diagnosisLaboratory diagnosis
1.1. Examination of vesicleExamination of vesicle
fluid under thefluid under the
electron microscope,electron microscope,
which shows roundwhich shows round
particles (brick-particles (brick-
shaped in smallpox)shaped in smallpox)
and may be used forand may be used for
cultivation of thecultivation of the
virus.virus.
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Laboratory diagnosisLaboratory diagnosis
2.2. Scrapings of floor ofScrapings of floor of
vesicles showvesicles show
multinucleated giant cellsmultinucleated giant cells
coloured by Giemsa staincoloured by Giemsa stain
(not in smallpox).(not in smallpox).
3.3. Serology is used mainlySerology is used mainly
for epidemiologicalfor epidemiological
surveyssurveys..
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1.1. Oral therapy with Acyclovir –Oral therapy with Acyclovir –
20 mg/kg/dose20 mg/kg/dose
maximum: 800 mg/dosemaximum: 800 mg/dose
4 doses per day X 5 days should4 doses per day X 5 days should
be used to treat uncomplicated Varicellabe used to treat uncomplicated Varicella
Treatment of uncomplicatedTreatment of uncomplicated
VaricellaVaricella
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2.2. Acyclovir guanine – 500 mg/mAcyclovir guanine – 500 mg/m22
8 hourly8 hourly
I.V. X 7 days.I.V. X 7 days.
Given within 72 hrs. prevents progressiveGiven within 72 hrs. prevents progressive
Varicella and visceral dissemination inVaricella and visceral dissemination in
high-risk patients.high-risk patients.
Drug therapy does not interfere withDrug therapy does not interfere with
induction of immunity.induction of immunity.
Treatment in high-risk patientsTreatment in high-risk patients
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3.3. Acyclovir also useful for treatment ofAcyclovir also useful for treatment of
Herpes zoster in dose of 500 mg/m2 or 10Herpes zoster in dose of 500 mg/m2 or 10
mg/kg 8 hourly.mg/kg 8 hourly.
Treatment of Herpes zosterTreatment of Herpes zoster
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PreventionPrevention
1.1. VZV transmission is difficult to preventVZV transmission is difficult to prevent
because the infection is contagious for 24-because the infection is contagious for 24-
48 hr before the rash appears.48 hr before the rash appears.
2.2. Infection control practices, includingInfection control practices, including
caring for infected patients in isolationcaring for infected patients in isolation
rooms with filtered air systems, arerooms with filtered air systems, are
essential.essential.
11/07/1711/07/17 6363

Prevention – Varicella VaccinePrevention – Varicella Vaccine
1.1. Composition : Live virus (min.Composition : Live virus (min.
2000 PFU) (Oka/Merck strain).2000 PFU) (Oka/Merck strain).
2.2. Efficacy : 95% (65%-100%).Efficacy : 95% (65%-100%).
3.3. Duration of : > 7 years.Duration of : > 7 years.
4.4. Vaccination Schedule : 1 DoseVaccination Schedule : 1 Dose
subcutaneous (<13 years of age).subcutaneous (<13 years of age).
5.5. May be administeredMay be administered
simultaneously with measles,simultaneously with measles,
mumps, and rubella (MMR)mumps, and rubella (MMR)
vaccine.vaccine.
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1.1. Routine vaccination at 15-18 months ofRoutine vaccination at 15-18 months of
age.age.
2.2. Recommended for all children withoutRecommended for all children without
evidence of Varicella immunity by theevidence of Varicella immunity by the
13th birthday.13th birthday.
Prevention –Prevention –
Varicella Vaccine for childrenVaricella Vaccine for children
11/07/1711/07/17 6565

Dr. Harivansh ChopraDr. Harivansh Chopra11/07/1711/07/17 6666
DOSE 0.5ML
SHELL LIFE 2 YEARS
ROUTE OF
ADMINSTRATION
SUBCUTANEOUS
IAP RECOMMENDS 2ND
DOSE AT 4-5 YEARS OF
AGE

1.1. Recommended to all personsRecommended to all persons >>13 years13 years
of age without evidence of Varicellaof age without evidence of Varicella
immunity.immunity.
2.2. Two doses separated by 4-8 weeks.Two doses separated by 4-8 weeks.
3.3. Do not repeat first dose because ofDo not repeat first dose because of
extended interval between doses.extended interval between doses.
Prevention – Varicella VaccinePrevention – Varicella Vaccine
for adolescents and adultsfor adolescents and adults
11/07/1711/07/17 6868

Varicella Vaccine –Varicella Vaccine –
Adverse ReactionsAdverse Reactions
1.1. Injection site complaints –Injection site complaints –
19% (children)19% (children)
24% (adolescents and24% (adolescents and
adults).adults).
2.2. Rash – 3 – 4% of vaccinees.Rash – 3 – 4% of vaccinees.
1.1. Rash may be maculopapular ratherRash may be maculopapular rather
than vesicular.than vesicular.
2.2. Average 5 lesions.Average 5 lesions.11/07/1711/07/17 6969

Zoster following VaccinationZoster following Vaccination
1.1. Most cases in children.Most cases in children.
2.2. Risk from vaccine virus less than fromRisk from vaccine virus less than from
wild virus.wild virus.
3.3. Usually a mild illness withoutUsually a mild illness without
complications.complications.
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Transmission of VaricellaTransmission of Varicella
Vaccine VirusVaccine Virus
1.1. Transmission of vaccine virus notTransmission of vaccine virus not
common.common.
2.2. Asymptomatic seroconversion may occurAsymptomatic seroconversion may occur
in contacts without evidence of Varicellain contacts without evidence of Varicella
immunity.immunity.
3.3. Risk of transmission increased if vaccineeRisk of transmission increased if vaccinee
develops rash.develops rash.
11/07/1711/07/17 7171

Varicella Vaccine –Varicella Vaccine –
Contraindications and PrecautionsContraindications and Precautions
1.1. Severe allergic reaction to vaccineSevere allergic reaction to vaccine
component or following a prior dose.component or following a prior dose.
2.2. Immunosuppression.Immunosuppression.
3.3. Pregnancy.Pregnancy.
4.4. Moderate or severe acute illness.Moderate or severe acute illness.
5.5. Recent blood product transfusion.Recent blood product transfusion.
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ConclusionsConclusions
1.1. Varicella or Chickenpox is a vaccineVaricella or Chickenpox is a vaccine
preventable disease occuring commonly inpreventable disease occuring commonly in
children.children.
2.2. It is characterized by fever & pleomorphicIt is characterized by fever & pleomorphic
rash in centripetal distribution.rash in centripetal distribution.
3.3. It causes many complications if it occursIt causes many complications if it occurs
in adults.in adults.
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MCQsMCQs
1.1. ““Pleomorphism” is the characterstic of rashPleomorphism” is the characterstic of rash
of :of :
1.1. Measles.Measles.
2.2. HHV – 3.HHV – 3.
3.3. Smallpox.Smallpox.
4.4. Fifth disease.Fifth disease.
Ans. – 2.
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MCQsMCQs
2.2. A child presenting with fever and VaricellaA child presenting with fever and Varicella
rash on day 1 :rash on day 1 :
1.1. Has already transmitted the virus to otherHas already transmitted the virus to other
children.children.
2.2. Is infectious to his siblings.Is infectious to his siblings.
3.3. Will continue to infect others for 4 – 5 days.Will continue to infect others for 4 – 5 days.
4.4. All of the above.All of the above.
5.5. Only 1 & 2 are correct.Only 1 & 2 are correct.
Ans. – 4.
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MCQsMCQs
3.3. Following are not false about “CongenitalFollowing are not false about “Congenital
Varicella Syndrome” except:Varicella Syndrome” except: (multiple choice)(multiple choice)
1.1. Risk of transmission is maximum in the 2Risk of transmission is maximum in the 2ndnd
trimester of pregnancy.trimester of pregnancy.
2.2. Extensive involvement of neurological system ofExtensive involvement of neurological system of
foetus.foetus.
3.3. Hyper-pigmentation of skin is pathognomic sign.Hyper-pigmentation of skin is pathognomic sign.
4.4. If fetus is born alive, may have problem inIf fetus is born alive, may have problem in
defecation and micturition.defecation and micturition.
Ans. – 1,3.
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MCQsMCQs
4.4. Complications of Varicella :Complications of Varicella : (multiple choice)(multiple choice)
1.1. Occur more commonly in children infectedOccur more commonly in children infected
within first 5 years of life.within first 5 years of life.
2.2. Pnuemonia is more common in adults.Pnuemonia is more common in adults.
3.3. Can be prevented by early administration ofCan be prevented by early administration of
Acyclovir.Acyclovir.
4.4. Varicella gangrenosa is a life-threateningVaricella gangrenosa is a life-threatening
infection caused by superaddedinfection caused by superadded ClostridiumClostridium
infection.infection.
Ans. – 2,3.
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MCQsMCQs
5.5. All are false about Varicella vaccine except :All are false about Varicella vaccine except :
(multiple choice)(multiple choice)
1.1. It may be given along with MMR vaccine (liveIt may be given along with MMR vaccine (live
vaccine).vaccine).
2.2. AIDS patients, not having previous history ofAIDS patients, not having previous history of
Varicella, should receive this vaccine.Varicella, should receive this vaccine.
3.3. The child is 100% protected for his entire life.The child is 100% protected for his entire life.
4.4. A susceptible female should be immunized in theA susceptible female should be immunized in the
first trimester of pregnancy itself .first trimester of pregnancy itself .
Ans. – 1.
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Differences between SmallpoxDifferences between Smallpox
and Chickenpoxand Chickenpox SmallpoxSmallpox
 Incubation – About 12Incubation – About 12
days (range 7-17 days)days (range 7-17 days)
 Prodromal symptoms -Prodromal symptoms -
Usually mildUsually mild
 Distribution of rash –Distribution of rash –
 - palms and soles- palms and soles
frequently involvedfrequently involved
 - axilla usually free- axilla usually free
 - rash predominant on- rash predominant on
extensor surfaces andextensor surfaces and
bony prominences
 ChickenpoxChickenpox
 About 15 days (range 7-About 15 days (range 7-
21 days)21 days)
 Usually mildUsually mild

 --
 seldom affectedseldom affected
 - axilla affected- axilla affected
 - rash mostly on flexor- rash mostly on flexor
surfacessurfaces
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Characteristics of the rashCharacteristics of the rash
 ––
 - deep-seated- deep-seated
 - vesicles multilocular- vesicles multilocular
and umbilicatedand umbilicated
 - only one stage of rash- only one stage of rash
may be seen at one timemay be seen at one time
 - No area of- No area of
inflammation is seeninflammation is seen
around the vesiclesaround the vesicles
 superficialsuperficial
 - unilocular; dew-drop- unilocular; dew-drop
like appearancelike appearance
 - rash pleomorphic, I.e.- rash pleomorphic, I.e.
different stages of thedifferent stages of the
rash evident at onerash evident at one
given time, because rashgiven time, because rash
appears in successiveappears in successive
cropscrops
 - an area of- an area of
inflammation is seeninflammation is seen
around the vesiclesaround the vesicles
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Evolution of rashEvolution of rash
 evolution of rash isevolution of rash is
slow, deliberate andslow, deliberate and
majestic, passingmajestic, passing
through definite stagesthrough definite stages
of macule, papule,of macule, papule,
vesicle and pustulevesicle and pustule
 - scabs begin to form- scabs begin to form
10-14 days after the10-14 days after the
rash aprash ap
 evolution of rash veryevolution of rash very
rapidrapid
 - scabs begin to form- scabs begin to form
4-7 days after the rash4-7 days after the rash
appearsappears
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FeverFever
- Fever subsides with the- Fever subsides with the
appearance of rash, butappearance of rash, but
may rise again in themay rise again in the
pustular stagepustular stage
(secondary rise of fever)(secondary rise of fever)

 Temperature rises withTemperature rises with
each fresh crop of rasheach fresh crop of rash
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Chickenpox (varicella) dr harivansh chopra

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