Varicella Follow Up

Monitoring

Further evaluation is needed, especially in immunocompromised patients. Observe for other bacterial, neurologic, respiratory, hepatic and hematologic complications in VZV infection. Appearance of rash in dermatomal distribution that is predictive of herpes zoster which usually follows a latent period of many years.  

Observe for the following in herpes zoster:

• Other bacterial, neurologic, ophthalmic, respiratory, hepatic and hematologic complications
• Persistent pain after 1-3 months of rash resolution is suggestive of PHN

Complications

Varicella  

Immunocompromised patients, neonates and adults (especially pregnant women) are most at risk for complications. The most common complication among healthy children is bacterial superinfection caused by Staphylococcus aureus or Streptococcus pyogenes that manifests as impetigo, furuncles, cellulitis, erysipelas or bullous skin lesions. A life-threatening disease known as necrotizing fasciitis has been reported as a complication in children. Extracutaneous complications are often neurologic, which includes acute cerebellar ataxia and meningoencephalitis. Reye’s syndrome, transverse myelitis, polyradiculitis, and Guillain-Barré syndrome may also occur but are rare.  Varicella pneumonia is the leading cause of varicella-associated morbidity among adults, pregnant individuals and immunocompromised individuals. Less frequent complications are arthritis, myocarditis and glomerulonephritis. Transient hepatitis occurs in most children and is usually asymptomatic, but fulminant liver failure may occur. Immune-mediated thrombocytopenia is associated with bleeding into skin lesions, petechiae, purpura, epistaxis, hematuria and GI hemorrhage.

Herpes Zoster  

Postherpetic Neuralgia (PHN)  

PHN is characterized as pain that persists in the affected area after resolution of the rash or for ≥3 months after onset of the rash. It is a common and debilitating complication of herpes zoster. The incidence of PHN is age-related and affects approximately 50% of patients >60 years old. Patient may experience constant pain (described as burning, aching or throbbing), intermittent pain (described as stabbing or shooting) and stimulus-evoked pain such as allodynia, which is defined as pain triggered by a non-painful stimulus (eg wind or a piece of clothing).  

Ophthalmic Zoster (Herpes Zoster Ophthalmicus)  

Ophthalmic zoster begins with fever, headache, decreased vision, droopy eyelid and a generalized feeling of being unwell accompanied by pain or extreme sensitivity of the eye, forehead and top of the head. One of the frequent complications of herpes zoster involving the nasociliary branch of the trigeminal nerve and has the potential to produce corneal ulceration accompanied by ocular palsy, lid ptosis, conjunctivitis, panophthalmitis, retinal vasculitis, retinal artery occlusion, optic neuritis, choroidal detachment, glaucoma and visual impairment which may lead to loss of vision.

Acute Retinal Necrosis (ARN)  

ARN is seen in patients with a history of herpes encephalitis and some immunocompetent patients. Rapid progression is characteristic in advanced acquired immunodeficiency syndrome (AIDS) with an 82% chance of bilateral eye involvement and 70% sustain retinal detachment.  Patients complain of blurring of vision and pain in the affected eye. Clinical features include acute iridocyclitis, vitritis, necrotizing retinitis, occlusive retinal vasculitis with rapid vision loss and retinal detachment. It causes a high rate of visual loss.  

Progressive Outer Retinal Necrosis (PORN)  

PORN occurs in AIDS patients with a CD4 count of <100 cells/μL. Ocular findings include minimal inflammation in the aqueous and vitreous humor, absence of retinal vasculitis, and multiple discrete peripheral lesions in the outer retinal layer. Lesions rapidly coalesce causing full-thickness retinal necrosis and subsequent retinal detachment. PORN causes high rates of vision loss.  

Ramsay Hunt Syndrome  

It is also known as herpes zoster oticus. It is a polycranial neuropathy with frequent involvement of cranial nerves V, IX and X. Ramsay Hunt Syndrome is reported in association with HSV type 2. Patients may experience ear pain, hearing loss, vertigo, facial nerve palsy and lesions in the auricle and auditory canal.  A less common complication involving the geniculate ganglion of the facial nerve presents as peripheral facial nerve palsy, tinnitus, vertigo, deafness, otalgia, loss of taste, vesicles on the ear, hard palate or tongue (herpes zoster oticus), nausea and vomiting.

Disseminated Herpes Zoster  

Disseminated herpes zoster can be serious to life-threatening. It spreads to other organs but mostly affects the lungs. Immunocompromised patients are more prone to danger. This occurs in patients with a CD4 count of <200 cells/μL. In patients with HIV co-infections, the CNS is the primary target. Symptoms include CNS vasculitis, multifocal leukoencephalitis, ventriculitis, myelitis and myeloradiculitis, optic neuritis, cranial nerve palsies, focal brainstem lesions and aseptic meningitis.  

Zoster-associated Encephalitis  

Delirium may occur a few days after vesicular eruption, before the onset of rash, or ≥6 months after a zoster episode. Most cases occur in immunosuppressed patients (eg HIV-infected individuals). Major risk factors include cranial or cervical dermatomal involvement, ≥2 prior episodes of zoster, disseminated herpes zoster and impaired cell-mediated immunity.  

Stroke Syndromes  

Stroke occurs secondary to infection of cerebral arteries, which may be due to direct VZV invasion of the arterial surface via spread along the intracranial branches of the trigeminal nerve. Granulomatous angiitis or ischemic stroke syndrome involves inflammation of the internal carotid artery or its branches from extension of infection in the trigeminal ganglion. It presents as an abrupt onset of severe headache and rapid evolution to contralateral motor weakness.  

Other Complications  

Dermatologic superinfections involve impetigo, cellulitis, necrotizing fasciitis and herpes gangrenosum. Transient segmental paralysis results in abdominal wall hernia and bladder dysfunction. Neurologic complications include meningoencephalitis, myelitis and zoster paresis depending on the affected dermatome (eg diaphragmatic paralysis, altered mentation).