Varicella( chicken pox) in children and adults - Causes, symptoms and treatment. MF.

Varicella( chicken pox, varicella) is an acute, highly anthropogenic( only in humans) virus infection transmitted by airborne droplet and by contact, accompanied by a vesicular rash and concomitant intoxication.

Varicella has been known since ancient times, but only at the end of the XVIII( 1800) it was separated as an independent disease, separate from smallpox, thanks to the works of Vogel.1911 - Aragao H. described small inclusions in the contents of vesicles - elementary bodies, considering them causative agents. The virus itself was isolated in 1940;1958 and 1972 - proof of the identity of the pathogen in patients with chicken pox and herpes zoster!

Chickenpox virus, model

Chickenpox causative agent

Chicken pox virus( Varictlla-herpes zoster is a type of herpesvirus infection of the third type) - a DNA-containing virus, the capsid of which is surrounded by a lipid envelope, which is possible and predetermines its lifelong presence in the body.

Chicken pox virus

Features of the chickenpox virus: rapidly spreads through the cell cultures( forms intracellular inclusions in epithelial cells) with subsequent destruction, capable of surviving in latent form through lifelong stays in the neurons of the spinal ganglia, as well as the facial and trigeminal nerve.

Chickenpox virus is unstable in the external environment, quickly dies at low and high temperatures, UVI and disinfectants, at room temperature can last up to several hours.

Susceptibility to the chickenpox virus is high( because it is very volatile - it covers distances up to 20 m, from floor to floor, on ventilation), especially for those who have not had chickenpox before or been vaccinated. Infection with chickenpox occurs even with fleeting contact with the patient. The seasonality of the disease is autumn-winter, and epidemic outbreaks are recorded every 5 years. Often children suffering from chicken pox are 5-9 years old, children under 6 months of age usually do not get sick because of antibodies received from the mother( if the mother has had chickenpox as a child).Adults also rarely get sick.

After the transferred infection, life-long immunity is formed, but in 3% of cases a repeated infection is observed. It should also be mentioned that previously infected people become not only carriers, but also sources when the infection worsens;their disease proceeds in the form of herpes zoster( shingles).

Causes of infection with chickenpox

Source - a patient with chicken pox and herpes zoster. Patients are infectious the day before the appearance of catarrhal symptoms( ie, until the prodromal period) and within 5 days of the onset of the rash. The transmission routes are airborne( when talking, coughing, loud crying, screaming), contact-everyday( saliva infection or vesicle discharge) and contact( at direct contact), transplacental( passage of the virus through the placental barrier).

Symptoms of chicken pox

The incubation period of chicken pox ( from the moment of introduction, to the first signs of chicken pox) is 11-23 days. During this period, the pathogen penetrates through the mucosa of the upper respiratory tract, then the multiplication and accumulation of this virus in the epithelial cells of these mucous membranes.

After maximum accumulation of the causative agent of varicella, it spreads through the lymphatic and blood vessels, causing the appearance of the following periods - prodromal or rash.

The prodromal period of chickenpox -( this period may not be) is only for a small part of people and lasts 1 day. Characterized by a scarlet fever-like rash with preservation in a few hours and their further disappearance, a rise in temperature to 37-38 ° C and intoxication. More often this period is a reaction to viremia.

Rash period - with chickenpox it begins acutely( or immediately after the prodromal period) and lasts for 3-4 days and more. More often, there is no time limit between them at all. Like the prodromal period, it is a response to viremia and is characterized by the following symptoms:

• an increase in regional lymph nodes( may not be),

• a fever of 37-39 ° C persists throughout the period of the rash and every new push of the rash is accompanied by a rise in temperature,

• a rash with chickenpox appears on the first day of intoxication, with podsypaniyami for 5 days - some already pass, and others just appear. Therefore, there is an impression of a false polymorphism( a variety of rashes in the same patient: bubbles, spots, and crusts at the same time).There is no favorite localization and staging, as in measles,( the rash can even be on the scalp - an important differential diagnostic feature, also on the oral mucosa, genital organs in girls, conjunctiva / cornea, larynx, with further ulceration and healing within 5days).Already for 1 day the red spot turns into a vial and after a couple of days the rash looks on the surface of the body as "drops of dew" with transparent contents, which becomes turbid after 1-2 days, and after 1-2 days the bladder dries up and turns into a crust falling awayin 1-3 weeks.

A patient with chickenpox stops being infectious as soon as the pods stopped and crusts formed. The rash is accompanied by an itch of varying intensity. With good antiseptic treatment of the rashes, they do not leave scarring behind, but if these hygiene rules are ignored, secondary contamination with bacteria from the surface of the skin occurs, followed by damage to the hermetic layer and scars / scars, as with smallpox, but not so gross.

Chickenpox rash( chicken pox)

• The recovery period lasts 3 weeks from the end of the rash and is characterized by the precipitation of crusts and the formation of lifelong immunity. After the falling off of the crusts, dark spots remain, but they pass for several weeks. Scars do not remain if there was no secondary infection.

This classic pattern is characteristic of varicella in children with normal immunity.

There are some contingents of people for whom varicella occurs most severely and with a high risk of complications, with a malignant variant of the course. Such a risk group includes: unimmunized pregnant women( danger to the fetus with possible disability), children in the first months of life from unvaccinated mothers, unimmunized adults( not vaccinated and not sick).In these cases, severe forms of chicken pox develop: hemorrhagic, gangrenous, bullous( see complications) .

Features of the course of chickenpox in different age groups of children and adults

Chicken pox in pregnant women

Intrauterine infection( possible in those pregnant who are not immunized - either did not have or had not been vaccinated):

- infection at 4 months of pregnancy - skin and bone pathology- underdevelopment of the limbs, the central nervous system, the organ of vision, the urinary system, the intestine, the retardation of intrauterine development, the lag in the psychomotor area. And after birth, mortality is 25%.

- at 6 months - embryo-fetopathies, similar at 4 months, does not occur, and after birth only symptoms of herpes zoster.

- chickenpox infection from the beginning of the 9th month of intrauterine stay and during the first 12 days of life, leads to a severe course, accompanied by the defeat of internal organs( lungs, heart, kidneys, intestines) with further joining of hemorrhagic syndrome. In this case, lethality reaches 50%

- If reinfection occurred( ie, repeated infection in a once-ill or grafted woman), several days before the birth( as shown above), the symptoms of the baby will develop immediately after birth and the windsmallpox will flow easily, because the antibodies from the mother will go to the baby even in utero, through the placenta.

Infection with chickenpox of infants( the first 3 months of life)

It is recorded very rarely, because maternal antibodies are given to the baby in utero through the placenta, but if this does not happen, then the following manifestations are observed:

• Prodromal period prolongs to 4 days with moderate /marked symptoms of intoxication;
• against a background of high temperature, general cerebral symptoms may join( visible pulsation of the fontanel will speak of increased intracranial pressure, convulsive alertness and other manifestations);
• Eruptions are profuse and slower the sequence( ie the formation of spots, then the bubbles, after the crusts and pigmentation) and the period of rashes acquires a protracted character - up to 9 days, instead of 5;
• There are often bacterial complications.

Features of chicken pox in adults

• More pronounced symptoms of intoxication;
• The rash does not appear on the first day, but on 2-3.Stages and the period of eruptions take on a protracted character.
• Frequent secondary bacterial infections, development of pneumonia and other complications.
• Itching is much stronger.

In adults, chickenpox often has complications( see below)

Diagnosis of chicken pox

1. Virological method - isolation of the causative agent of chickenpox from vesicles and sloughing skin lesions. But it takes time and is used only in disputable cases.

2. The express method - RIF( immunofluorescence reaction), with the help of it, the detection of viral antibodies is carried out.

3. Serological - ELISA( enzyme immunoassay) - is aimed at the detection of specific antibodies IgM and G to the varicella zoster virus;M-appear in the incubation period( hourly 4-7 days from the moment of infection) and persist for 2 months, Their presence indicates an acute period;G-appear on the 2-3 week and persist for life, they indicate immunization, ie, protection.

4. Genetic method - the use of PCR( polymerase chain reaction) is aimed at detecting the DNA of the virus.

5. General clinical tests: OAK( ↓ Lc, ↑ Lf, normal ESR).Immunological examination: ↓ T-lymphocytes, violation of the B-cell link, ↑ activity of NP and macrophages, ↑ CIC( circulating immune complexes).

In fact, the listed methods of diagnosis are used by doctors not often, often the diagnosis is made on the basis of complaints and examination, which assesses the nature of the rashes, which in general is not correct, and the tests are prescribed already in case of complications.

Treatment of chickenpox

Often, according to an old habit, a doctor who diagnoses chicken pox does not prescribe any treatment other than antipyretic drugs and lubrication of a rash of green matter - at the stage of modern medicine development this is not entirely correct. Such a set of medicines can be limited only if chickenpox flows easily, there is little rash, the baby eats well and feels well. In other cases, in children and in the treatment of varicella in adults, etiotropic treatment aimed at eliminating the virus is mandatory! Remember that the varicella-zoster virus after the illness has been left in the body for life and can subsequently manifest itself as herpes zoster, therefore, the more effective etiotropic treatment is, roughly speaking, the more a virus dies, the less chance it will be to get health problems in the future.

1. Etiotropic treatment of varicella zoster

- Virocidal preparations directed specifically against herpes viruses:
• acyclovir = zovirax = virolex( from 2 years);
• valciclovir( from age 12),
• famciclovir( with 17 years), isoprinosine;Also use Acyclovir-ointment on the rashes and with conjunctivitis( eye damage).

- Immunomodulators: interferon, viferon

- Immunostimulants: tsikloferon, anaferon

- Antibiotics are used for secondary bacterial complications, and the drug of choice are cephalosporins of the 3rd generation.

In severe cases of chicken pox, immunoglobulins are administered intravenously. All of the above drugs should be used in age-related dosages. If the child of the first year is ill, the treatment is only under the supervision of the doctor with possible hospitalization, because the course of infectious processes in young children proceeds with a tendency to generalization, frequent and severe complications and high lethality !

2. Pathogenetic treatment of chicken pox

- Bed rest period 3-5 days( with complicated course longer)

- Thorough skin and mucous care:

• Hygienic bath / shower, after not rubbing the skin and slightly soak with towel,
• Treatmentrashes greens to prevent secondary infection,
• treatment of the oral mucosa - rinsing with furacillin and / or sodium sulfacil, or sodium hydrobobanate;
• With conjunctivitis, acyclovir ointment can be used to prevent bacterial complications - 20% albucid, levomycitin ointment or tetracycline.

- Abundant alkaline drink

- In severe currents, immunomodulators stronger( thymolin, thymogen, IRS-19) and cytokine preparations( Ronkeylikin),

- Multivitamins, probiotics( bifidum-lactobacterin, linex), enterosorbents( smecta), metabolic therapy medications according to indications( riboxin, cocarboxylase), mucolytics / expectorants( ambroxol, bromhexine, Chebreus broth, thoracic collection # 1) and anti-inflammatory aerosols in drycough( Erespal), antiaggregants( actovegil, cavinton, etc.), antihistamines( with pronounced itching apply local - fenistil gel or gistan, or other antihistamine ointments, and inside use antihistamines suprastin, tavegil, etc.);antipyretics( ibuprofen, nurofen, or physical methods of cooling - wrapping).

3. Symptomatic treatment is appointed from the series of pathogenetic groups of drugs or in more serious complications - cardiac glycosides.

Treatment lasts an average of 2 weeks( including medication).

Rehabilitation after the transferred chickenpox

• a month after recovery, the doctor examines the outbreak, with the appointment for immunological examination and passage of specialists,

• protective mode for 2 weeks after recovery( release from physical exertion),

• withdrawal from preventive vaccinations for 2 months,

• appointment within a month: multivitamins and / or vitamin-mineral complexes, metabolic therapy and plant adaptogenes.

Complications of chickenpox

Complications of chickenpox are often associated with the attachment of bacterial microflora, besides this contributes to the immunosuppressive function of the chicken pox virus, as a result, develop: gingivitis, stomatitis, purulent parotitis, conjunctivitis, keratitis, otitis, sepsis, pneumonia, glomerulonephritis, encephalitis,myelitis, nephritis, myocarditis, keratitis, Reye's syndrome, arthritis, laryngitis.

But the most serious complication is the hemorrhagic form of the chicken pox , in which the vesicles are filled with hemorrhagic content( blood) = "bloody dew", multiple hemorrhages to the skin / mucous / nosebleeds / hemoptysis / gastrointestinal tract and other organs.

Gangrenous form is characterized by the appearance of large flabby bubbles, with a necrosis zone, a scab. After the falling off of the blisters, ulcers are formed, which quickly become infected, resulting in the development of sepsis and a fatal outcome soon. But all the serious complications develop against the background of immunodeficiencies, taking glucocorticosteroids( GCS) or hormones.

Reye's syndrome can also lead to death. At the heart of the syndrome is fatty liver infiltration with the development of hypoglycemia, a significant increase in the level of transmnaz, coagulopathy, an increase in the content of ammonia and the level of fatty acids, the formation of toxic metabolites that cause direct damage to neurons, demyelination, cerebral edema. Symptoms of the syndrome - nausea, vomiting, delirium, epileptic seizures with the development of coma. Because of the danger of Reye's syndrome, you should not prescribe aspirin to children under 11 years of age with any viral infections, including chickenpox, in which the risk of this complication is so increased. Reye's syndrome occurs exclusively at the age of 15 years.

For any symptoms of atypical chickenpox, call a doctor immediately.

Chronic varicella prophylaxis

• In the absence of contraindications( immunodeficiency states( IDS), the recent term of treatment for SCS / immunosuppressant / hormones, acute illnesses or exacerbation of chronic), vaccination against chickenpox vaccine - Varilrix, Okavax, Prevenar orPneumo-23( the last 2 are still against pneumococcal infection);

• Passive immunoprophylaxis is used by the introduction of "Varicella-Zoster-Immunoglobulin" - VZIG, it is necessary: ​​individuals with IDS;to all newborns whose mothers did not have chickenpox or had caught a few days before the birth;all preterm to 1 kg, regardless of the infectious anamnesis of the mother.

• Nonspecific prophylaxis of varicella - quarantine( isolation of the patient) within 5-7 days from the beginning of the rash, with periodic ventilation and wet cleaning of the premises. All unimmunized contacts are isolated up to 21 days.

Kindergartens and schools with a mass incidence of varicella in quarantine, as a rule, do not close.

Therapist doctor Shabanova I.Е.