UCONN Emergency Medicine Interest Group

EM Images #6

In IMAGES on August 13, 2011 at 7:22 PM

Syndicated from the UCONN EM Residency website; credit to Dr. London, Dr. Bolton, Dr. Hitesh Shah for images and text.

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History:
A 25 year old male presented to HH ED in May 2009 complaining of 5 days of an itchy, scattered, worsening rash over his entire body. The rash began on his back and scalp, then spread to his arms, and is now everywhere. He was seen at a nearby clinic 5 days ago and sent home with Benadryl and Hydrocodone. He saw the PMD again 2 days ago and was also given Prednisone, Keflex, Permethrin, and Triamcinolone without relief. The rash was pruritic; he reported a sore throat and dysphagia from pain of oral lesions. He denied fever, cough, SOB, URI, conjunctivitis, congestion, runny nose, difficulty breathing, sick contacts, alleviating factors, exacerbating factors. Pt is an immigrant from Honduras and lives with his parents and his 1 year old child; he has been in the US for 4 years.

Physical Exam:
Vital Signs –T 98.2, P 111, R 16 –BP 146/89, O2 Sat 98%
Gen: Hispanic male, sitting, NAD
HEENT: NC/AT, MMM, PERRL, sclera anicteric, – JVD/LAD
Chest: Tachycardic, + S1/S2, CTAB
Back: No CVAT
Abdomen: + normoactive BS, soft, NTND, no r/g/HSM
Neurological: Awake, alert, oriented, cogent, nonfocal, MAE
Extremities: wwp, no c/c/e
Skin: see images

What is the diagnosis?


Varicella.

ED course:
CXR was performed, and patient was seen by an ID  consultant (note: according to ID, countries with tropical and semitropical climates have a higher incidence of adult chickenpox compared with countries with a temperate climate (eg. United States, European countries). The case was reported to the Department of Public Health. Patient was advised to stop all medications except Benadryl. He was discharged on acyclovir.

Key points:
Varicella is usually a clinical dx (as in our case), but one can do Tzanck preparations from the base of the lesion or antibody-linked fluorescent microscopy testing. In patients without obvious severe illness, do CXR; if no respiratory sx, not immunocompromised and CXR is negative, they may be discharged home on antivirals (see below).
Testing for complications may be done as directed by history and exam, which may include LFTs for hepatitis and CSF for meningitis/encephalitis.

Discussion:
Varicella -Zoster virus, or Human Herpes Virus 3, is the etiology for both varicella (chickenpox) AND herpes zoster (shingles). It is highly contagious and has more than 90% household contact transmission rates via aerosolized droplets from nasopharyngeal secretions of infected patient or direct contact with vesicular fluid. Airborne precautions are recommended. Varicella affects approximately 4 million children/year in USA with 60 million/year worldwide. Most cases occur in children <9 years old (typically 3-6 years old). It has a seasonal propensity, with most cases occurring in late winter/early spring. Prior to the vaccine, there were ~10,000 hospitalizations/year in the USA and ~100-150 deaths/year.  Since the vaccine introduction in 1995, there has been a significant decrease in infection, hospitalization rates, and mortality. The clinical presentation of varicella classically involves a sudden onset of an array of symptoms including fever, malaise, headache, pharyngitis, anorexia, and the characteristic rash. Adults may have severe constitutional symptoms and skin eruption may be delayed 1-2 days. The rash initially presents as macules, then becomes papular, followed by the appearance of the characteristic 2-3 mm vesicles on an erythematous base (the so-called “dew drop on a rose petal”) for hours to several days, which then becomes pustular, and finally, crusts over and falls off in 5-20 days. Lesions appear in different crops on trunk (highest density) and on scalp, face, extremities. Importantly, there are several stages of the rash present at any one time during the course of the disease (unlike smallpox). The rash may occur anywhere on the skin and mucous membranes.

Management:
Do NOT give children aspirin because of the risk of inducing Reyes’ syndrome. Acetaminophen may be used for fever, antihistamines, Calamine lotion, and Aveeno (oatmeal) baths for pruritis. Keep fingernails trimmed short. Acyclovir is recommended for children with chronic illness, steroids, immunosuppression, as well as all adults (dosage 20 mg/kg/dose up to 800 mg five times daily for seven days; best within 24 hours of rash; in pneumonia and in the immunosuppressed, dosage is 10 mg/kg/dose q8 hours for seven days given IV) Note that the IV form of acyclovir can cause reversible renal failure. For infection control, recommend airborne precautions, and have patients avoid the immunocompromised. The incubation period is 13-17 days, and patients are contagious 5 days before vesicles and 5 days after.  Susceptible individuals are contagious 10-21 days after exposure.  Susceptible health care workers are recommended to avoid pts with varicella/zoster until all vesicles are crusted and dried. Check titers in pregnant women, immunocompromised patients, if negative, VZ immunoglobulin should be given within 96 hours.

Complications:
Disseminated disease may occur in high risk groups including the immunosuppressed (especially children with leukemia), neonates less than 10 days old, mothers in perinatal period (5 days before and 2 days after delivery). Fetal infection may occur causing varicella embryopathy (limb atrophy, scarring on extremities, CNS, ocular manifestations). Other complications include bacterial superinfection, pneumonia (most adult hospitalizations are for this; mortality rate 10-30%; higher risk in males, smokers, pregnant women, immunosuppressed), meningitis/encephalitis, sepsis (usually children), thrombocytopenia, arthritis, hepatitis, glomerulonephritis.

Disposition:
Healthy children and healthy adults without complications may be discharged home. Admission criteria include immunosuppressed status or immunocompetent adults with complications.

References:

  • Albrecht, MA. Clinical features of varicella-zoster virus infection: Chickenpox. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2009.
  • Albrecht, MA. Treatment of varicella-zoster virus infection: Chickenpox. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2009.
  • Lichenstein R. Pediatrics, Chickenpox or varicella. In: eMedicine, 2008 Sept. <http://emedicine.medscape.com/article/ 800546-overview>
  • Marx JA, Hockberger RS, Walls RM et al., eds. Rosen’s Emergency Medicine Concepts and Clinical Practice. 6th ed. Philadelphia, PA: Elsevier; 2006: 1858-1859, 2042-2043.
  • Tintinalli JE, Kelen GD, Stapczynski JS., eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw Hill; 2004: 873.
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