What Are the Indications for Use of Acyclovir and Post-Varicella Immunization in a Healthy Patient?

Patient Presentation
A 14-year-old female came to clinic with a low-grade fever and rash. The fever began 2 days previous and the rash was noticed on the trunk last evening.
She lived in a group home because of severe mental retardation and mild cerebral palsy.
Her caretaker said that the rash was on the trunk and was spreading with more lesions appearing since the prior evening.
The rash also appeared pruritic because she was picking at her shirt.
She had some decrease in her appetite but was drinking well. Others at the group home had upper respiratory infections recently.
She had no recent travel, new soaps, lotions, or different outside experiences where she could contact different plants. She was current on all her vaccinations.
The review of systems was otherwise normal.
The pertinent physical exam showed she had a temperature of 100.5° F, but the rest of her vital signs were normal.
Her mucus membranes were moist, and she had minor clear rhinorrhea. Lungs were clear and heart was normal.
The skin lesions were vesicular with an erythematous base. There were ~15 lesions but this was increased from ~ 5 lesions the night before. None of the lesions were crusted.
Neurologically, she was non-verbal but could follow simple directions and was relatively cooperative. She had repetitive rocking motions and had increased tone in all extremities.
The diagnosis of varicella was made. Using the American Academy of Pediatrics recommendations, the patient was given oral acyclovir as she was within 72 hours of the rash onset, was at increased risk for severe varicella because of her age (> 12 years) and also because she was in a group home setting where secondary cases may be more severe.
Additionally, the group home and public health was contacted so that the other residents and staff members could receive post-exposure varicella vaccination and/or varicella immunoglobulin. Public health was also following up on her school contacts for the same reasons.
The physician recommended isolation of the patient in her room until the lesions were crusted. He also discussed comfort measures that could be taken, when the patient could return to school, and signs and symptoms that indicate to call or return to the clinic.

Varicella zoster virus is a DNA virus in the herpes family.
It is transmitted by respiratory secretions or direct contact with skin lesions with an usual incubation period of 10-21 days after contact.
Patients are contagious 1-2 days before the rash until the lesions are crusted over.
There usually is a prodrome of fever, malaise, headache and upper respiratory symptoms.
Crops of pruritic lesions occur generally beginning on the trunk and then spreading to face and extremities.
The lesions are described as “a dewdrop on a rose petal” for the vesicular lesion on an erythematous base, but the lesions often occur in various stages from papular, vesicular, pustular and crusted.
Mucous membranes can be involved also.
The main complications in immunocompetent people are suprainfection and scarring of the skin.
However, especially in immunocompromised patients, pneumonia, encephalitis, myelitis, meningoencephalitis, and acute cerebellar ataxia can occur.
Case fatality in the general population is ~7/100,000 or 100-150 deaths/year in the U.S. Hospitalizations occur in ~10,500 people/year because of varicella.
Varicella, especially in the first 20 weeks of pregnancy, can lead to multiple congenital abnormalities. Perinatal varicella (defined as 5 days before to 2 days after delivery) puts the neonate at risk for disseminated neonatal varicella because the virus crosses the placenta without time for antibody to pass transplacentally.
Vaccination decreases the incidence of the disease and if the disease still does occur (which happens in 15-20% of patients after 1 vaccine dose), the disease is modified with fewer lesions, faster resolution and fewer complications.
In the U.S., 2 doses of vaccine are recommended protect the 10-30% of children who do not receive protection from the first dose, not because of waning immunity.

Learning Point
For healthy, immunocompetent individuals with varicella, supportive treatment is recommended; oral acyclovir is not recommended.

Oral acyclovir should be considered because of the increased risk of moderate or severe disease in otherwise healthy patients who are > 12 years of age, have cutaneous or pulmonary chronic problems, are on long-term salicylate therapy and people receiving even short courses of corticosteroids (both oral and aerosolized).

Oral acyclovir can give a modest decrease in symptoms and if used it should be begun as soon as possible as viral replication is stopped by 72 hours after the rash.

For susceptible individuals (susceptible meaning never had chickenpox, or not having two vaccines)
who are otherwise healthy and > 12 months of age, post-exposure vaccination with varicella vaccine within 72 hours and possibly up to 120 hours, may prevent of modify the disease and should be considered. Post-exposure vaccination may not prevent all disease.

Immunocompromised individuals are treated much more aggressively including possible hospitalization, administration of intravenous antivirals, and possible administration of varicella immunoglobulin or intravenous immunoglobulin.

In the case above, many of the group home residents were considered at risk because of their age, they had underlying health problems, and were living in a group setting where the risk of secondary cases and complications are higher.
Additionally, many residents and caretakers in the home hadn’t received their second dose of varicella vaccination because the recommendation for 2 doses of vaccinewas changed relatively recently (2006) and there were ongoing vaccine shortages.

Remember that salicyclates should be stopped if a child is exposed or has varicella disease. Acetaminophen is recommended instead.

Questions for Further Discussion
1. If this was varicella zoster, how would the treatment recommendations change?
2. How is neonatal varicella treated?
3. What are the definitions of evidence of immunity to varicella?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for this topic: Chickenpox
and at Pediatric Common Questions, Quick Answers for this topic: Chickenpox

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

American Academy of Pediatrics. Varicella-Zoster Infections, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;711-725.

Centers for Disease Control. Varicella Disease Questions & Answers.
Available from the Internet at http://www.cdc.gov/vaccines/vpd-vac/varicella/dis-faqs-gen.htm (rev. 5/10/2007, cited 9/10/2007).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills

    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    October 30, 2007