Clinical features of varicella-zoster virus infection: Chickenpox
- Mary A Albrecht, MD
Mary A Albrecht, MD
- Associate Professor of Medicine
- Harvard Medical School
- Section Editors
- Martin S Hirsch, MD
Martin S Hirsch, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Viral Infections
- Professor of Medicine
- Harvard Medical School
- Sheldon L Kaplan, MD
Sheldon L Kaplan, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Infectious Diseases
- Professor and Vice Chairman for Clinical Affairs
- Baylor College of Medicine
Varicella-zoster virus (VZV) is one of eight herpesviruses known to cause human infection and is distributed worldwide. VZV infection causes two clinically distinct forms of disease: varicella (chickenpox) and herpes zoster (shingles). Primary VZV infection results in the diffuse vesicular rash of varicella, or chickenpox. Endogenous reactivation of latent VZV typically results in a localized skin infection known as herpes zoster, or shingles.
Primary varicella infection in children is generally a mild disease compared to more severe presentations in adults or immunocompromised patients of any age. The rates of infection, hospitalizations, and mortality have all declined in the US since the introduction of the varicella vaccine in 1995; immunization is recommended in all children before the age of five years and in nonimmune adults. (See "Vaccination for the prevention of shingles (herpes zoster)" and "Epidemiology of varicella-zoster virus infection: Chickenpox".)
The major clinical manifestations and complications of chickenpox will be reviewed here. Infection in the neonate and the treatment and prevention of this infection, including the varicella vaccine, and herpes zoster are discussed separately. (See "Varicella-zoster infection in the newborn" and "Treatment of varicella (chickenpox) infection" and "Vaccination for the prevention chickenpox (primary varicella infection)" and "Measles, mumps, and rubella immunization in adults" and "Clinical manifestations of varicella-zoster virus infection: Herpes zoster" and "Vaccination for the prevention of shingles (herpes zoster)".)
TRANSMISSION AND VIROLOGY
Chickenpox is highly contagious, with secondary household attack rates of >90 percent in susceptible individuals [1,2].
Infection control issues within hospitals are discussed elsewhere. (See "Prevention and control of varicella-zoster virus in hospitals".)
- Straus SE, Ostrove JM, Inchauspé G, et al. NIH conference. Varicella-zoster virus infections. Biology, natural history, treatment, and prevention. Ann Intern Med 1988; 108:221.
- Wharton M. The epidemiology of varicella-zoster virus infections. Infect Dis Clin North Am 1996; 10:571.
- Leclair JM, Zaia JA, Levin MJ, et al. Airborne transmission of chickenpox in a hospital. N Engl J Med 1980; 302:450.
- Dumas AM, Geelen JL, Mares W, Van Der Noordaa J. Infectivity and molecular weight of varicella-zoster virus DNA. J Gen Virol 1980; 47:233.
- Harper DR, Gilbert RL, Jeffries DJ. Molecular biology of varicella-zoster virus. A review prepared for the UK Advisory Group on Chickenpox. J Infect 1998; 36 Suppl 1:1.
- Cohen JI, Brunell PA, Straus SE, Krause PR. Recent advances in varicella-zoster virus infection. Ann Intern Med 1999; 130:922.
- Lin TY, Huang YC, Ning HC, Hsueh C. Oral acyclovir prophylaxis of varicella after intimate contact. Pediatr Infect Dis J 1997; 16:1162.
- Grose C. Variation on a theme by Fenner: the pathogenesis of chickenpox. Pediatrics 1981; 68:735.
- Ozaki T, Ichikawa T, Matsui Y, et al. Viremic phase in nonimmunocompromised children with varicella. J Pediatr 1984; 104:85.
- Heininger U, Seward JF. Varicella. Lancet 2006; 368:1365.
- Gershon AA, Steinberg SP, Gelb L. Clinical reinfection with varicella-zoster virus. J Infect Dis 1984; 149:137.
- Junker AK, Angus E, Thomas EE. Recurrent varicella-zoster virus infections in apparently immunocompetent children. Pediatr Infect Dis J 1991; 10:569.
- Arvin AM, Koropchak CM, Wittek AE. Immunologic evidence of reinfection with varicella-zoster virus. J Infect Dis 1983; 148:200.
- Hall S, Maupin T, Seward J, et al. Second varicella infections: are they more common than previously thought? Pediatrics 2002; 109:1068.
- Chaves SS, Zhang J, Civen R, et al. Varicella disease among vaccinated persons: clinical and epidemiological characteristics, 1997-2005. J Infect Dis 2008; 197 Suppl 2:S127.
- Weinmann S, Chun C, Mullooly JP, et al. Laboratory diagnosis and characteristics of breakthrough varicella in children. J Infect Dis 2008; 197 Suppl 2:S132.
- Marin M, Watson TL, Chaves SS, et al. Varicella among adults: data from an active surveillance project, 1995-2005. J Infect Dis 2008; 197 Suppl 2:S94.
- Centers for Disease Control and Prevention (CDC). Recommended childhood immunization schedule--United States, January-June 1996. MMWR Morb Mortal Wkly Rep 1996; 44:940.
- Choo PW, Donahue JG, Manson JE, Platt R. The epidemiology of varicella and its complications. J Infect Dis 1995; 172:706.
- Gnann JW Jr. Varicella-zoster virus: atypical presentations and unusual complications. J Infect Dis 2002; 186 Suppl 1:S91.
- Laupland KB, Davies HD, Low DE, et al. Invasive group A streptococcal disease in children and association with varicella-zoster virus infection. Ontario Group A Streptococcal Study Group. Pediatrics 2000; 105:E60.
- de Benedictis FM, Osimani P. Necrotising fasciitis complicating varicella. Arch Dis Child 2008; 93:619.
- Shirley R, Mackey S, Meagher P. Necrotising fasciitis: a sequelae of varicella zoster infection. J Plast Reconstr Aesthet Surg 2011; 64:123.
- Vugia DJ, Peterson CL, Meyers HB, et al. Invasive group A streptococcal infections in children with varicella in Southern California. Pediatr Infect Dis J 1996; 15:146.
- Zurawski CA, Bardsley M, Beall B, et al. Invasive group A streptococcal disease in metropolitan Atlanta: a population-based assessment. Clin Infect Dis 1998; 27:150.
- Johnson R, Milbourn PE. Central nervous system manifestations of chickenpox. Can Med Assoc J 1970; 102:831.
- Dangond F, Engle E, Yessayan L, Sawyer MH. Pre-eruptive varicella cerebellitis confirmed by PCR. Pediatr Neurol 1993; 9:491.
- Häusler M, Schaade L, Kemény S, et al. Encephalitis related to primary varicella-zoster virus infection in immunocompetent children. J Neurol Sci 2002; 195:111.
- Guess HA, Broughton DD, Melton LJ 3rd, Kurland LT. Population-based studies of varicella complications. Pediatrics 1986; 78:723.
- Preblud SR. Age-specific risks of varicella complications. Pediatrics 1981; 68:14.
- Fleisher G, Henry W, McSorley M, et al. Life-threatening complications of varicella. Am J Dis Child 1981; 135:896.
- Kleinschmidt-DeMasters BK, Amlie-Lefond C, Gilden DH. The patterns of varicella zoster virus encephalitis. Hum Pathol 1996; 27:927.
- Fairley CK, Miller E. Varicella-zoster virus epidemiology--a changing scene? J Infect Dis 1996; 174 Suppl 3:S314.
- Poscher ME. Successful treatment of varicella zoster virus meningoencephalitis in patients with AIDS: report of four cases and review. AIDS 1994; 8:1115.
- Cinque P, Bossolasco S, Vago L, et al. Varicella-zoster virus (VZV) DNA in cerebrospinal fluid of patients infected with human immunodeficiency virus: VZV disease of the central nervous system or subclinical reactivation of VZV infection? Clin Infect Dis 1997; 25:634.
- Hurwitz ES, Nelson DB, Davis C, et al. National surveillance for Reye syndrome: a five-year review. Pediatrics 1982; 70:895.
- Hurwitz ES, Barrett MJ, Bregman D, et al. Public Health Service study on Reye's syndrome and medications. Report of the pilot phase. N Engl J Med 1985; 313:849.
- Belay ED, Bresee JS, Holman RC, et al. Reye's syndrome in the United States from 1981 through 1997. N Engl J Med 1999; 340:1377.
- WEBER DM, PELLECCHIA JA. VARICELLA PNEUMONIA: STUDY OF PREVALENCE IN ADULT MEN. JAMA 1965; 192:572.
- Hockberger RS, Rothstein RJ. Varicella pneumonia in adults: a spectrum of disease. Ann Emerg Med 1986; 15:931.
- Triebwasser JH, Harris RE, Bryant RE, Rhoades ER. Varicella pneumonia in adults. Report of seven cases and a review of literature. Medicine (Baltimore) 1967; 46:409.
- Schlossberg D, Littman M. Varicella pneumonia. Arch Intern Med 1988; 148:1630.
- Feldman S. Varicella-zoster virus pneumonitis. Chest 1994; 106:22S.
- Haake DA, Zakowski PC, Haake DL, Bryson YJ. Early treatment with acyclovir for varicella pneumonia in otherwise healthy adults: retrospective controlled study and review. Rev Infect Dis 1990; 12:788.
- Mer M, Richards GA. Corticosteroids in life-threatening varicella pneumonia. Chest 1998; 114:426.
- Ellis ME, Neal KR, Webb AK. Is smoking a risk factor for pneumonia in adults with chickenpox? Br Med J (Clin Res Ed) 1987; 294:1002.
- Esmonde TF, Herdman G, Anderson G. Chickenpox pneumonia: an association with pregnancy. Thorax 1989; 44:812.
- HARRIS RE, RHOADES ER. VARICELLA PNEUMONIA COMPLICATING PREGNANCY. REPORT OF A CASE AND REVIEW OF LITERATURE. Obstet Gynecol 1965; 25:734.
- Floudas CS, Kanakis MA, Andreopoulos A, Vaiopoulos GA. Nodular lung calcifications following varicella zoster virus pneumonia. QJM 2008; 101:159.
- Varicella death of an unvaccinated, previously healthy adolescent — Ohio, 2009. MMWR Morb Mortal Wkly Rep 2013; 62:261.
- Wilkins EG, Leen CL, McKendrick MW, Carrington D. Management of chickenpox in the adult. A review prepared for the UK Advisory Group on Chickenpox on behalf of the British Society for the Study of Infection. J Infect 1998; 36 Suppl 1:49.
- Feldhoff CM, Balfour HH Jr, Simmons RL, et al. Varicella in children with renal transplants. J Pediatr 1981; 98:25.
- Patti ME, Selvaggi KJ, Kroboth FJ. Varicella hepatitis in the immunocompromised adult: a case report and review of the literature. Am J Med 1990; 88:77.
- Soriano V, Bru F, González-Lahoz J. Fatal varicella hepatitis in a patient with AIDS. J Infect 1992; 25:107.
- Kusne S, Pappo O, Manez R, et al. Varicella-zoster virus hepatitis and a suggested management plan for prevention of VZV infection in adult liver transplant recipients. Transplantation 1995; 60:619.
- Pitel PA, McCormick KL, Fitzgerald E, Orson JM. Subclinical hepatic changes in varicella infection. Pediatrics 1980; 65:631.
- Dits H, Frans E, Wilmer A, et al. Varicella-zoster virus infection associated with acute liver failure. Clin Infect Dis 1998; 27:209.
- Rogers SY, Irving W, Harris A, Russell NH. Visceral varicella zoster infection after bone marrow transplantation without skin involvement and the use of PCR for diagnosis. Bone Marrow Transplant 1995; 15:805.
- Anderson DR, Schwartz J, Hunter NJ, et al. Varicella hepatitis: a fatal case in a previously healthy, immunocompetent adult. Report of a case, autopsy, and review of the literature. Arch Intern Med 1994; 154:2101.
- Sherman RA, Silva J Jr, Gandour-Edwards R. Fatal varicella in an adult: case report and review of the gastrointestinal complications of chickenpox. Rev Infect Dis 1991; 13:424.
- García-Doval I, Pérez-Zafrilla B, Descalzo MA, et al. Incidence and risk of hospitalisation due to shingles and chickenpox in patients with rheumatic diseases treated with TNF antagonists. Ann Rheum Dis 2010; 69:1751.
- Nguyen HQ, Jumaan AO, Seward JF. Decline in mortality due to varicella after implementation of varicella vaccination in the United States. N Engl J Med 2005; 352:450.
- Gershon AA, Mervish N, LaRussa P, et al. Varicella-zoster virus infection in children with underlying human immunodeficiency virus infection. J Infect Dis 1997; 176:1496.
- TRANSMISSION AND VIROLOGY
- Transmission routes
- Incubation period
- CLINICAL MANIFESTATIONS
- Uncomplicated varicella
- Impact of vaccine on clinical manifestations
- COMPLICATIONS OF VARICELLA
- Skin/soft tissue infections
- Neurologic complications
- - Encephalitis
- - Reye syndrome
- IMMUNOSUPPRESSED HOSTS
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS