ZS
21 day old ♀
‘Chicken pox in the neonate’
Content
1. Case presentation
2. Varicella
- clinical features
- differential diagnosis
- treatment
- complications
- vaccination
D1 assessment
Call to A&E resus from A&E SpR requesting Paed support
S
21/7 old with chicken pox in respiratory distress
B
4/7 hx of varicella, with recent infection of sibling.
Unremarkable birth history.
A
Oxygen via NRBM, preparing to obtain iv access and take blds
R
Immediate attendance of Paeds consultant
Assessment in A&E resus
A
Self maintained, no added sounds.
B
Self ventilating in air. Sats 92% A. Oxygen applied via NRBM
at 10L, sats 100%. Increased effort of breathing. Tachypnoic
>70 RR/min. Tracheal tug, recession ++. AE reduced
throughout, no wheeze/crackles.
C
Crt 2-3 sec. Tachycardic 170 bpm. Mild-moderate dehydration.
Pale.
D
BM 4.5. Alert & responsive. Not encephalopathic. Tone, power
and reflexes normal. Fontanelle normotensive. Temp 36.8
E
Abdomen soft, no organomegally, slightly full.
Widespread varicella skin lesions.
Immediate management in A&E resus
Oxygen to maintain O2 sats >95%
iv access
Blood cultures, FBC, CRP, U&E, VBG
iv cefotaxime & flucloxacillin
iv aciclovir
CXR
Fluid bolus 0.9% normal saline 10ml/kg
Maintenance ivf 10% dextrose + 0.18 NaCl
Admit Paeds, for incubator care in HDU, continuous sats
monitoring
VBG in A&E :
pH 7.31, pCO2 7.45, pO2 5.64, HCO3 24.2,
BE -2.0, Lactate 2.7, Glu 4.5
A&E Resus
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PMC
4/7 varicella, 1/7 reduced feeds, 4 hours of respiratory distress.
HPC
Born AGH 38/40, NVD. Normal preg, scans & birth. ?IUGR in
later stages of pregnancy. No SCBU. BW 2.64 kg.
Consanguineous parents (1st cousins).
Whilst 8 months pregnant, baby’s nephew had chicken pox.
Mother therefore given immunoglobulin (see hadn’t had
chicken pox before).
Baby’s one year old sister has recently had chickenpox
which resolved 5/7 ago.
Up until this evening, baby has been well. Was feeding by
breast 3 hourly, alert, no fever, wet nappies x3/d, BO x2/d
HPC
Parents have been in touch with GP three times over the
phone in the last 5/7. Told “providing feeding well and skin
lesions improving then no concerns.”
At 1700hrs on day of admission, increased breathing rate
and not feeding. Parents phones GP. Told to take to A&E.
PMH/ FH
Consanguineous parents. Baby’s nephew has a VSD.
Had BCG vacc at birth, nil else.
Results
Blds
from
A&E
CBG
After 6 hrs
Hb 15.9
WCC 27.3
Neu 14.7
Plt 246
pH 7.32
pO2 5.8
pCO2 7.6
CRP 24
Na 135
K 6.0
Urea 3.0
Cl 95
HCO3- 28.8
BE 1.4
Na 140
K 4.3
Ca 1.02
Cl 102
Glu 4.9
D2
Summary of WR review D2
O2 requirement overnight upto 50%, currently 28% O2 sats 99%
RR70, HR 150-200, temp 38.3 despite antipyretic and reduced incubator
Temp, ivf 19ml/hr 10% dex + 0.18%NaCl. PU good amounts. BO normal. NBM
CBG pH 7.3, pCO2 8.2, HCO3 29.5, BE +1.1, Glu 5.2, Na 139, K4.0
O/E moderate recession, more marked on handling. Resp effort slightly
irreg. Tracheal tug & head bobbing. Decreased AE all areas esp RUZ.
Widespread fine creps. Crt 3 sec. Irritable on handling.
Plan:
normal saline bolus 10ml/kg
regular CBG
NG tube, aspirate air
repeat CXR
explained to family, may deteriorate further or become tired
necessitating respiratory support +/- transfer
liase with PICU LGI
Wd 17
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Day 2
Liaison with PICU consultant LGI:
Made aware of possible need for transfer; no further suggestions regarding Mx.
PICU team spoke to virologists, nil to add.
1430hrs D2
CBG
pH 7.27, pCO2 9.0, pO2 5.8, HCO3 30.3, BE +1.3, Glu 5.5, Na 140,
K3.6
Oxygen requirement unchanged. Repeat CXR reviewed, RUZ
consolidation improved, still extensive pneumonitis
Plan:
Needs CPAP
May need PICU for ventilation
Tolerated nasal CPAP, less tachycardic, improved tachypnoeic, crt <2 sec,
O2 100%
Consultant reviews on three further occasions with CBG sampling during
the afternoon.
D2
CBG results day 2
time
0900
1430
1725
2000
2245
pH
7.30
7.27
7.33
7.31
7.36
pCO2
8.2
9.0
7.8
7.38
6.54
4.28
5.24
pO2
5.8
HCO3
29.5
30.3
30.3
27.8
27.6
BE
+1.1
+1.3
+2.6
+0.8
+1.6
Na
139
140
141
140
140
K
4.0
3.6
4.8
4.4
4.1
Ca
1.05
1.03
Cl
102
102
4.5
3.5
Glu
5.2
5.5
4.9
CPAP
Transferred to PICU
D2
Further liaison with PICU consultant LGI throughout the afternoon.
Decided that in view of CPAP and possible requirement for ventilation
to transfer to LGI. EMBRACE transfer arranged.
Arrived at PICU apyrexial and normal obs except RR 55 and O2 94% CPAP.
CPAP discontinued as unsettled. Flow-by 5L O2 started.
PICU plan :
Iv fluids 100 ml/kg/day (0.45% NaCl + 10% dextrose)
Start feeds EBM via NGT 2ml/hr and gradually increase if tolerating
Continue iv fluclox + aciclovir
Switch iv cefotaxime to ceforoxime
D/W microbiology mane
CBG. Leave off CPAP for time being.
Monitor BMs
Transferred from PICU day 3
Reviewed mane, no CPAP overnight. Less respiratory distress. O2 96%
with flow-by O2 5L. CBG CO2 7.7, pH 7.32.
D/W Micro consultant
Since ceforoxime has good Step & Staph coverage the fluclox can be
Stopped. Ceforoxime is preferred choice over cefotaxime.
Recommends send respiratory secretions for viral & bacterial culture.
Transferred back to AGH by EMBRACE after only one night at LGI
Aciclovir and cefuroxime iv.
Ivf and NG feed of EBM at 100ml/kg/day
Flow-by O2.
Stable
D3
Summary of WR review D4
O2 requirement still needing 0.2L/min, afebrile, RR 45-60, HR 140-160
Feeding 3 hourly bolus via NGT, 120ml/kg/day, on aciclovir and ceforoxime.
O/E settled, asleep, no resp distress, chest clear, CVS NAD, crt <2 sec,
Abdo NAD with 1-2cm liver, healing skin lesions
Plan:
try breast feeding
continue iv meds
Summary of WR review D5
Sats 100% on 3L O2. Some short bradycardias overnight. Now on C&G prem.
Tolerating some oral feeds. PU’ing. BO. Parents feel she is much better.
O/E alert and moving all limbs. Chest clear with some subcostal recession.
CVS NAD. ABDO NAD. Fontanelle normotensive. Oral thrush. Clinically
nappy rash. Skin lesions heeling well.
Plan:
start oral nystatin
dactarin gel for nappy area
continue aciclovir, stop tomorrow on D5
continue iv abx to complete 7/7 course then for oral abx for 7/7
chase blood cultures (NAD)
monitor feeding, if struggling then may need to return to NGT feeds
Summary of WR review D6
No oxygen requirement overnight. No respiratory distress. Feeding well.
Discharged on oral ceforoxime 7/7
48 hr ward access
For OPD r/v with Paed consultant in 3/52, repeat CXR
OPD
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Varicella
Chickenpox is a highly infectious, acute contagious disease predominantly of
children under 10 years old, though it may occur at any age. Peak incidence Mar
– May. It is characterised by fever and a rash, and is caused by varicella zoster virus
Around 90% of people who come into contact will develop the disease.
Transmission is through 1) direct person to person contact 2) airborne droplet
infection 3) through contact with infected articles such as clothing and bedding
Around 90% of adults over the age of 18 years have immunity for VZV in the UK
Reactivation of latent VZV will result in shingles which is more common in adults
In England and Wales, the incidence of chickenpox is approximately 1290
cases per 100,000 person-years
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Varicella – clinical features
The incubation period is from 14 up to 21 days
chicken pox is infectious from a few days before the onset of rash develops and not more than six days after
first lesions appear
the rash begins as macular lesions which develop into papular, or vesicular lesions (filled with fluid) and later
becomes pustular
chickenpox rash has a centripetal distribution - mostly on the face and trunk and sparsely on the limbs
there is erythema around the lesions and they are intensely itchy
usually the rash peaks at around 48 hours in immunocompetent people
vesicles dry and crust over, and sometimes scar if scratched to excess oropharynx and genital tract
mucous membranes may be involved as well
new lesions can emerge for up to 5 days
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Varicella
In children under 10 years, the disease is usually mild and self limiting, but a more severe
infection can be seen in
1) adults - especially in pregnant women and in smokers since they are
at an increased risk of developing fulminanting varicella pneumonia
2) neonates
3) immunosupressed individuals – there is an increased risk of developing
disseminated or haemorrhagic varicella
Signs of severe infections include:
•respiratory symptoms (clinical respiratory signs are often absent).
•densely cropping vesicles
•haemorrhagic rash
•bleeding from gums, haemoptysis, GI bleeding
•any neurological changes - cerebellar signs, encephalopathy
•persisting fever with new vesicles >6 days after onset
General recommendationis for school exclusion for 5 days from onset of rash
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Differential diagnosis
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herpes simplex
disseminated herpes zoster
impetigo
drug related eruptions
contact dermatitis
erythema multiforme
Stevens Johnson syndrome
hand, foot and mouth disease
scabies
disseminated molluscum contagiosum
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Treatment
Treatment is usually symptomatic in milder disease paracetamol or ibuprofen can be given to
reduce flu like symptoms, fever and pain
antivirals should be considered for patients who presents within 24-48 hours of new vesicles
(indicating an evolving disease) antiviral therapy should be continued for at least 1 week
oral aciclovir may also be given to 1) immuocompetent adults and older adolescents
2) Infants 3) severe infection at any age 4) immunosuppression 5)severe cardiorespiratory
disease 6) chronic skin disorder
Varicella zoster immune globulin (VZIG) VZIG prophylaxis can be used in individuals who
complete all of the following criteria:
•significant exposure to chickenpox or herpes zoster
•a clinical condition that increases the risk of severe varicella, this includes immunosuppressed
patients, neonates and pregnant women
•no antibodies to VZ virus
Immunosuppressed patients should be given immunoglobulin to varicella zoster and aciclovir
within two days of contact with varicella. If they develop chicken pox they should be treated with
aciclovir.
Antibiotics should be given for secondary infections
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Complications
Majority of children recover without any complications but neonates, adults,
pregnant women and those who are immunocompromised may have more
serious complications
Pulmonary involvement…….5-14% of adults
CNS involvement…….cerebellar ataxia and/or encephalitis
Secondary bacterial infections….inc osteomyelitis
Haemorrhagic complications…..GI bleeds, DIC, cerebral bleeds
In pregnancy…..significant maternal mortality and congenital VAR syndrome
Others….. arthritis, glomerulonephritis, myocarditis, and purpura fulminans
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Varicella vaccination
Varicella vaccine is a lyophilised preparation which contains live attenuated organisms
of the Oka strain of varicella zoster virus.
•should be administered as deep subcutaneous injection and can be given together with
other live vaccines such as MMR
•children from one year to under 13 years of age; a single dose of varicella vaccine will
give protection for around 90% of children
•children aged 13 years or older and adults - should receive two doses of varicella vaccine
four to eight weeks apart, around 75% will have protection against clinical chickenpox (1)
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