• Chickenpox( chicken pox) symptoms

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    Chicken pox( chickenpox) is an extremely contagious, acute infectious disease of viral etiology that affects mainly young children. Characterized by the appearance of a vesicle rash, partly reminiscent of smallpox, and minor disorders of the general condition of the patient and symptoms of intoxication. How to treat this ailment with folk remedies, look here.

    Etiology. The causative agent of varicella( herpesvirus type 3) belongs to the family. Herpesviridae, subfamily Alfaherpesviridae. By its biological properties is close to the herpes simplex virus. The virus has an internal core of double-stranded DNA, surrounded by a protein shell of icosahedral symmetry. This nucleocapsid is encased in an envelope. The converted form has a diameter of 150-200 nm, and a "bare"( without envelope) virion - 100 nm. In epithelial cells forms intranuclear inclusions( body-inclusions).

    The peculiarity of VVZ is high volatility - with the air current it spreads over long distances( up to 20 m).The virus is unstable in the external environment, quickly dies at low and high temperature, the action of UFO, so the final disinfection after the patient is not carried out. Targets for VVZ are spike-like skin cells and epithelium of mucous membranes. After the primary infection, the virus persists for life in the neurons of the spinal ganglia, the ganglia of the facial and trigeminal nerves. Like all herpesviruses, VVS has immunosuppressive activity - it leads to disruption by factors of congenital resistance, immune response by humoral and cellular types.

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    Epidemiology. Varicella is one of the most common human diseases, especially in childhood. Annually 500 thousand - 1 million children suffer from chicken pox in our country. Antibodies to VVZ are found in 60% of children aged 6 years, 90 - at the age of 12 years and 95% - at the age of 15 years. The source is sick with chicken pox and herpes zoster. Ways of transmission of airborne vehicles - airborne, contact-household, vertical.

    A patient with chickenpox is dangerous one day before the onset of the rash, the entire period of rashes and within the next 3-4 days after their cessation. The virus is released into the environment from the contents of the vesicles on the mucous membranes and the skin of the patient. With the air current, the airspace spreads over long distances. Infection occurs even with fleeting contact. The epidemic danger of patients with herpes zoster is small, since the isolation of the virus from the nasopharynx is short-lived and not in all patients.

    The epidemic recovery is marked in the autumn-winter period. An increase in the incidence is observed every 4-6 years. The index of contagiosity is 0.9-1.0.Children of 5 to 9 years are often ill. Children of the first 2-3 months of life are ill rarely due to the presence of maternal antibodies. Repeated cases of varicella are rarely recorded( 2-3%).

    Pathogenesis. The entrance gate for VVZ is the mucous membrane of the upper respiratory tract. The following stages of the pathogenesis of varicella are distinguished.

    1. Primary replication of VVZ.The virus multiplies rapidly enough at the entrance gate and accumulates in a significant amount.

    2. Viralemia. With the flow of blood, the VVZ is carried throughout the body and enters the skin, mucous membranes, and the nervous system. Viruses with chicken pox are wavy in nature, which leads to repeated body temperature rises and the appearance of new elements of the exanthema for several days.

    3. Development of serous inflammation. After the VHF enters the spine-like layer of the epidermis, capillaries expand, which clinically manifests as spots. Then, serous edema develops, lymphocyte-macrophage infiltration, leading to the appearance of papules. Cells of the epidermis undergo ballooning degeneration. As a result of the separation of cells from each other cavities are formed, which quickly fill with lymph - a vesicle is formed. The reverse development of vesicles begins with the resorption of exudate. The lid of the bubble sinks, a crust is formed. The papillary layer of the dermis, as a rule, remains intact, so the scar is most often absent. As a result of dissemination, the VVZ enters the nervous system and internal organs, but the morphological changes in them are minimal. Only in generalized forms under the conditions of IDS the virus exhibits neurotropic and viscerotropic properties.

    4. Development of purulent inflammation. As a result of immunosuppressive activity of VVZ, secondary microflora is attached and bacterial complications are formed.

    5. Development of the immune response. Of decisive importance in antiviral immunity are factors of congenital resistance and immune response by cellular type involving T-lymphocytes( CD8), natural killer cells( CD16) and the interferon system. The resulting antibodies play only an indirect protective role. As a result of the immune response, the virus disappears from the blood, skin and mucous membranes.

    6. Lifetime persistence. Immunity with chicken pox is non-sterile and does not ensure sanation of the body from the VVZ.The virus persists for life in the spinal ganglia, the nuclei of the cranial nerves, which innervate the skin areas most affected by primary infection. Reactivation of the VVZ occurs under conditions of IDS, which clinically manifests itself in the form of herpes zoster.

    The classification of VF is used. Uchaikina and N.I.Nisevich( 1990).

    I. Mechanism of occurrence:




    Acquired varicella, .The duration of chickenpox is as follows.

    The prodromal period occurs only in some patients. It is characterized by malaise, fever to subfebrile digits, the appearance of a scarlet fever or a koreal-like rash( "res"), which persists for several hours.

    After prodromal events or among complete health, the body temperature rises to 37.5-39 ° C, the patient's condition worsens and a rash appears. In the beginning, it has the form of a spot, which in a few hours turns into a papule, then into a vesicle. Vesicles small, 0.2-0.5 cm in diameter, located on a non-infiltrated base, surrounded by a corolla of hyperemia, their wall is tense. Single-chamber vesicles. In the first day they resemble dewdrops. On the second day, the transparent content becomes turbid, after 1-2 days the vesicle dries up and turns into a crust that disappears after 1-3 weeks. After the separation of the crusts there is pigmentation or a depigmented spot, the scar usually does not form.

    Eruption occurs not simultaneously, but in an impulsive manner for 3-4 days. As a result, the skin contains elements at different stages of development - "false polymorphism".

    Eruptions are localized on the face, scalp, trunk, extremities( minimally on distal sections).There is a tendency to preferential localization of the rash in the places of the greatest irritation of the skin and pressure on it. The rash is accompanied by a slight itch. Simultaneously with skin rashes, there is a rash on the mucous membranes, conjunctiva, cornea, larynx, genitalia. Bubbles quickly macerated and ulcerated. Healing of erosions occurs in 3-5 days.

    The entire period of rashes retains a fever( 3-4 days), which has an incorrect character, and a moderate intoxication. Generalized lymphadenopathy can develop.

    Rudimentary form occurs in children with residual specific immunity, in individuals who received immunoglobulin or blood products in the incubation period. Characterized by an easy current. It is accompanied by the appearance of ungainly patchy-papular rashes, which do not always reach the bubble stage. The disease occurs against the background of normal body temperature and a satisfactory general condition.

    Hemorrhagic form is one of the severe, malignant variants of chicken pox. It develops in patients with IDS and / or who receive glucocorticoid hormones and cytostatics, can occur in newborns. The disease is accompanied by severe intoxication, high body temperature, multiple organ pathology and hemorrhagic syndrome, which manifests itself in the form of hemorrhagic contents of vesicles, hemorrhage into the skin, subcutaneous tissue, mucous membranes, internal organs, nosebleeds, gastrointestinal tract, hemoptysis, hematuria. This form is called lightning purple. It can end with a fatal outcome.

    The visceral form is common in newborns, prematurity or in older children with IDS.It flows heavily, accompanied by severe and prolonged intoxication, high fever, a profuse rash. There is a defeat of internal organs - liver, lungs, kidneys, adrenals, pancreas, spleen, endocardium, digestive tract, nervous system, etc. Often ends with a fatal outcome.

    Gangrenous form develops in patients with IDS, it is very rarely recorded. Characterized by severe intoxication, prolonged course, the appearance of large flabby bubbles, which are quickly covered with a scab and necrosis zone. After the fall of the scab, deep ulcers are exposed, the healing of which is slow. Often, the disease is complicated by sepsis and ends lethal.

    Among specific complications, encephalitis and meningoencephalitis most often develop, more rarely - myelitis, nephritis, myocarditis, etc. Neurological complications are associated with both direct neurotropism of the virus and with an immune response leading to demyelination of nerve fibers.

    Encephalitis can occur at the height of the rash or in the period of convalescence. In the first case, the development of encephalitis is associated with the penetration of the virus into the central nervous system by axonal or hematogenous pathways and reflects the severity of the infectious process. Against the background of febrile fever, there are general cerebral symptoms( headache, vomiting, convulsions, impaired consciousness), in some patients - meningeal signs. In the future, focal symptoms and hemiparesis come to the fore. In the liquorgram, lymphocytic pleocytosis and an increase in the protein content are detected.

    Encephalitis in the period of convalescence( 5-14 days of illness) can develop with any form of severity of the disease. As a rule, cerebellitis occurs( acute cerebellar ataxia).There are general cerebral symptoms( lethargy, headache, vomiting) and symptoms of cerebellar involvement( tremor, nystagmus, ataxia, dysarthria, muscle hypotension).Meningeal symptoms are absent or mild. In the liquorgram, moderate lymphocytic pleocytosis and a normal protein content are detected.

    Features of chicken pox in infants. In children of the first three months of life, chickenpox develops very rarely, as they receive transplacental antibodies from the mother. However, in cases where the mother did not suffer from varicella, the transmission of antibodies does not occur, and after contact the child falls ill at the earliest age.

    In this case, chicken pox is characterized by the following features:

    Intrauterine chicken pox. The incidence of chickenpox among pregnant women is 5/10 thousand Vertical transmission VVZ can occur in the antenatal and intrapartum periods. Clinical forms of intrauterine varicella are embryophytopathy( congenital varicella) and neonatal varicella.

    When infected in the first 4 months of pregnancy, the baby is born with a clinic of congenital varicella syndrome. The risk of developing embryo-fetopathy in the first trimester is 2%, in the second trimester - 0.4%.Skin pathology( areas of scarring with a clear distribution to dermatomes, multiple scarification, hypopigmentation), bones, central nervous system, organ of vision, urinary system, intestine, intrauterine growth retardation, lag in psychomotor development are noted. Mortality during the first months of life is 25%.Infection after the 20th week of pregnancy does not lead to embryopathy, the latent form of congenital chicken pox develops. Over the next few months, the child may have a clinic for herpes zoster.

    Neonatal chicken pox is a disease that develops as a result of infection in the last 3 weeks of pregnancy, during childbirth and during the first 12 days of a child's life. In children whose mothers get chicken pox five days before the birth and within the first three days after the symptoms of the disease appear on the 5th-10th days of life. In connection with the absence of maternal antibodies, chickenpox in these children is quite difficult, accompanied by the defeat of internal organs( lungs, heart, kidneys, intestines), joining hemorrhagic syndrome, complications and high lethality( up to 30%).When a pregnant woman is sick for 6-21 days before delivery, the clinic for chicken pox develops immediately after birth. As the mother is transmitted transplacentally to the mother's antibodies, the disease usually develops favorably.

    The diagnosis of varicella is based on epidemiological history, clinical and laboratory examination. Methods for laboratory diagnosis of varicella are as follows.

    Virological - are aimed at the isolation of VVZ in tissue cultures of cells infected with fluid from vesicles or skin lesions.

    Express methods - the main method is the reaction of immunofluorescence, which allows to detect viral antigens in syco-ba or smears taken from the base of vesicular lesions.

    Molecular-genetic - determination of DNA virus in vesicular fluid, blood and CSF by polymerase chain reaction( PCR).The real-time PCR method allows determining the virus titer in biological fluids, cells, biopsy samples.

    Serological - by ELISA the antibodies IgM and IgG to the VVZ are determined. IgM antibodies appear 4-7 days after infection and persist for 1-2 months. IgG antibodies begin to be synthesized at the 2-3 rd week and persist throughout life.

    In the blood test, there is leukopenia, lymphocytosis, normal ESR.In the study of immune status, T-cell immunodeficiency, violations from the B-cell link, interferon status, functional activity of neutrophils, macrophages, increase in the CEC are recorded.

    Differential diagnosis .List of diseases for the differential diagnosis of the syndrome "Vesicle rash":

    I. Infectious diseases:

    II.Noninfectious diseases:

    Reference diagnostic signs of varicella.

    Herpes zoster develops in patients who have suffered varicella, unlike chicken pox characterized by the presence of grouped vesicles located along the sensory nerves, the appearance of which is preceded by severe pain syndrome.

    Disseminated form of herpes simplex infection( IPG) develops in young children, in immunocompromised patients. Unlike chicken pox, the disseminated form of IPG is characterized mainly by heavy flow, the appearance of grouped vesicles in various parts of the skin with a tendency to fuse. For this form of IPG is characterized by polyorganism lesions( encephalic syndrome, or encephalitis, enlargement of the liver, spleen, etc.).

    Enterovirus infection( viral pemphigus of the extremities and oral cavity, HFMK disease), like chicken pox, begins with an increase in body temperature, the appearance of symptoms of intoxication, vesicular rashes on the skin and oral mucosa. However, unlike chicken pox, the rash is localized to the distal parts of the limbs( brushes, feet).Typical arrangement on the brush are the back and side surfaces of the fingers, on the feet - the fingers and the edge of the sole. The rashes are represented by vesicles 1 - 3 mm in diameter, surrounded by a hyperemic aureole, less often by thin-walled blisters or bright red spots. Vesicles are opened with the formation of ulcers, which heal within a week. On the oral mucosa, bright red spots, vesicles and sores with predominant localization in the cheek region are found. There may be other manifestations of enterovirus infection - herpangina, catarrhal symptoms, diarrhea, myalgia, myocarditis, serous meningitis, polyradiculoneuropathy, encephalitis.

    The human disease with vesicle rickettsiosis occurs as a result of a bite of gamasid mites. In contrast to chickenpox, vesicle rickettsiosis is characterized by the presence of primary affect at the site of the tick bite, prolonged exposure( up to 20 days), fever during the week.

    Monkeypox can occur in humans, including children who have contact with sick animals 7-14 days before the disease. It differs from chicken pox with the presence of a two-wave fever, a sufficiently pronounced intoxication, the appearance of a polymorphous rash( true polymorphism) on the 3-4th day of the disease, prolonged preservation of crusts( up to 2-3 weeks), scar formation.

    Paravaccine, in contrast to chicken pox, develops in individuals who have contact with animals( cows, sheep, pigs).Exanthema appears against the background of normal temperature and a satisfactory general condition, has a favorite localization( hands) and is characterized by a combination of vesicles with dense, painless nodules.

    Multiforme exudative erythema is characterized by the formation of bullous elements. However, at the beginning of the disease, the rash is polymorphous - spotty, papular, vesicular. These rashes quickly merge into the erythematous fields, then bubbles form, after the opening of which there are erosions. This disease must be differentiated with a gangrenous form of chicken pox. However, unlike chicken pox, the rash appears on the 4-6th day from the onset of the disease, its appearance is preceded by fever, intoxication, myalgia, arthralgia, an intermediate element - erythema.

    Unlike chicken pox, Stevens-Johnson syndrome is a serious disease accompanied by a high fever, marked intoxication, in which there are spots, papules, and blisters besides the vesicles. The latter are quickly opened, forming sharply painful erosive areas. A feature of the disease is a massive lesion of the mucous membranes. Often the disease is preceded by the use of sulfonamide drugs.

    After insect bites, rashes are more often represented by papules, but some elements may resemble vesicles. However, unlike chickenpox, rashes associated with insect bites are not accompanied by fever, intoxication. They are located only on the open areas of the body and are absent on the scalp, on the mucous membranes, for them polymorphism is not characteristic.

    Exanthema for urticaria only in rare cases resembles chicken pox. For this disease, in contrast to chicken pox, are characterized by endless elements - urticaria, often irregular in shape, towering above the surface of the skin, having a pale center, accompanied by itching. The appearance of a rash is associated with exposure to an allergen - food, medication, toxic.

    Impetigo is an infectious disease of the skin of streptococcal or staphylococcal etiology, which is characterized by the formation of cavitary elements - pustules, fliken. With the staphylococcal nature of the disease, these elements are associated with the sebaceous-hair follicles and sweat glands, the contents of which are immediately represented by pus. With streptococcal etiology, the process is not associated with the sebaceous-hair follicles and sweat glands. The content is first transparent, and then becomes cloudy. This type of impetigo must be differentiated from chicken pox. However, unlike chicken pox, the appearance of rashes with impetigo is not accompanied by fever and intoxication, the rash is localized more often on the face, neck, extremities. Elements have peripheral growth, are quickly opened, dried and covered with crusts. The appearance of new elements can occur in the absence of appropriate therapy for several weeks. If the hygiene rules are not respected, it is possible to contaminate others by contact.

    Patients with severe forms of chicken pox and with complications development( encephalitis, meningoencephalitis, myelopathy, Reye's syndrome, nephritis, laryngitis with laryngeal stenosis) are hospitalized. Hospitalization is carried out in the Mel'tserovsky box. The rest of the patients are treated at home.

    All patients are assigned bed rest: for the usual course of chicken pox for 3-5 days, with complications, its duration is determined by the severity of the condition.

    Patients need thorough care of the skin and mucous membranes, which helps prevent complications. Recommend a daily change of linen, hygienic bath. Vesicles are treated with a 1% solution of brilliant green. After eating, rinse your mouth with boiled water or a disinfectant solution( furacilin, chamomile broth, calendula, 2% solution of sodium hydrogencarbonate).The eyes are washed with a solution of furacilin 1: 50 000. When a purulent discharge occurs, a 20-30% solution of sodium sulfacyl is instilled.

    Etiotropic therapy involves the appointment of several groups of drugs.

    1. Virocidal preparations are abnormal nucleosides( acyclovir, valaciclovir, famciclovir), inosine pranobex. Acyclovir is effective only at the beginning of treatment in the first 24 hours after the onset of the rash. Taking into account the higher resistance of VVZ to acyclovir in comparison with HSV-1 and HSV-2, the dose of the drug is increased. With a mild and moderate form, acyclovir is administered orally for 7-10 days. In severe and complicated forms, the drug is administered intravenously drip for 7-10 days with a subsequent transition to oral administration. The ointment of acyclovir is applied to the affected surface of the skin, used for conjunctivitis. In children older than 12 years of life, it is possible to use valacrox( valtrex), in adolescents over 17 years of age and in adults famciclovir( famvir).Doses of these drugs also increase. Inosin pranobex suppresses replication of VVZ, other herpesviruses, RNA-containing viruses and has immunomodulating activity.

    2. Interferon preparations are used in the form of rectal suppositories or inside with light and medium-heavy forms( viferon, genferon light, kipferon, reaferon-EU-lipint).Viferon is prescribed one candle twice a day daily for 5-10 days. Children under 7 years of age use viferon-1, in patients older than 7 years of life - viferon-2.The ointment of viferon is applied to the affected areas. A single dose of genferon light in the form of rectal suppositories in children younger than 7 years is 125 thousand ME, over 7 years - 250 thousand ME.Start therapy - 1 candle 2 times a day for 10 days, supporting treatment - 1 candle per night every other day for 1-3 months. In severe and complicated forms, intramuscular administration of reaferon, realiron, roferon A, intron A, etc. is prescribed.

    3. Interferon inducers are used for light and moderate forms( tsikloferon, neovir, amixin, kagocel, anaferon, poludan).Locally apply liniment of tsikloferon and poludan.

    4. Immunoglobulins are prescribed for severe and complicated forms of the disease. Immunoglobulins with an increased content of antibodies to VVZ for intramuscular( VZ1G, Varicellon) and intravenous administration( Varitect), as well as immunonin, intraglobin, intrathect, octagam, pentaglobin, etc. are used.

    5. Antibiotics are used in the development of pustular, bullous, gangrenous forms of the windsmallpox and bacterial complications. Use protected aminopenicillins, modern macrolides, cephalosporins of the 3rd generation, carbapenems.

    Pathogenetic therapy includes detoxification in light and medium-heavy forms in the form of abundant drinking, with severe and complicated forms - in the form of intravenous drip infusions of glucose-salt solutions. Under the control of the immunogram, immunocorrecting drugs are used - immunomodulators( thymalin, takvin, thymogen, imunophane, polyoxidonium, lycopide, imunorix, derinat, sodium nucleic acid, neupogen, IRS-19, ribomunil, bronchomunal, immunomax, etc.) and cytokine preparations( leukinferon, Roncoleukin).Assign multivitamins, vitamin-mineral complexes, probiotics( bifiform, linex, bifidum bacteria forte, etc.), enterosorbents( smecta, enterosgel, filterum, polyphepan, etc.), according to indications - drugs of metabolic therapy( riboksin, kokarboksilaza, cytochrome C,Elmkar, mucolytics and expectorants( ambroxol, bromhexine, mucaltin, licorice root, etc.), protease inhibitors( triacal, gordoks, trasilol), antiaggregants( cavinton, pentoxifylline, cinnarizine, actovegin), oxygen therapy, antihistamines. With pronounced itching, it is preferable to use first-generation antihistamines( dimedrol, diazolin, suprastin, tavegil, fenkarol).Glucocorticoids are used only with encephalitis.

    Symptomatic therapy includes the appointment of cardiac glycosides and antipyretic drugs( paracetamol, cefecon D, ibuprofen).Acetylsalicylic acid is categorically contraindicated because of the danger of developing Ray's syndrome!

    According to the indications after 1 month, the pediatrician examines the convalescence of chicken pox, conducts an immunological examination, appoints a consultation of specialists( neurologist, pulmonologist, immunologist, etc.).The child needs a protective mode for 2 weeks, a withdrawal from preventive vaccinations for 2 months. Rehabilitation therapy includes the appointment of multivitamins, vitamin-mineral complexes, metabolic therapy and plant adaptogen for 1 month. Under the control of the immunogram, immunomodulators are used.

    Varicella vaccination is not included in the National Schedule of Prophylactic Inoculations. The WHO European Office recommends the introduction of selective vaccination of patients with leukemia in the period of remission( duration of more than one year against the background of maintenance therapy) and individuals awaiting organ transplantation. In Russia it is recommended to vaccinate children with oncohematological pathology. Apply live attenuated vaccines "Varilrix"( GlaxoSmithKline) and "Varivax"( Merck, Sharp and Dome).For passive specific prophylaxis, "Varicella-Zoster-Immuno-Globulin"( VZIG) is used. It is carried out by contact persons with IDS in a dose of 125 mg( 1.25 ml) / 10 kg of body weight during the first 48 hours from the moment of contact( no later than 96 hours).

    Nonspecific prevention consists in isolating the patient, which is most often performed at home. In the hospital, children with chicken pox are placed in the Mel'tserovsky box. The patient is isolated until the 5th day after the last rash. Final disinfection is not carried out, after the patient perform ventilation and wet cleaning of the premises. Contact persons under the age of 3 years who have not been sick with chicken pox are suspended from visiting the children's collective for the period from 11 to 21 days from the moment of contact with a sick chicken pox or herpes zoster. After contact, daily observation is carried out with the conduct of thermometry, examination of the skin and mucous membranes. Healthy children who did not suffer from varicella in the first 72 hours after contact with the patient may be vaccinated with varicella zoster vaccine. As a chemoprophylaxis from the 7-9th day of contact, acyclovir is prescribed in a dose of 40-80 mg / kg per day with a course of 5-14 days.

    Given the adverse consequences, great importance is now attached to the prevention of congenital and neonatal varicella, which is performed in the gravity and postnatal stages. Newborns who were in contact with a sick chicken pox and do not have maternal antibodies, intramuscularly injected VZIG at a dose of 125 mg. The drug is assigned to the following patient contingents:

    Newborns whose mothers are ill with chickenpox 5 days before the birth and within the first 2 days after giving birth should be supervised in a hospital setting. At the first symptoms of chicken pox they are prescribed acyclovir intravenously at a dose of 10-15 mg / kg 3 times a day for 7 days.