A 5 Year Old Child Presents With Mild Fever And A Rash

A 5 year-old child is brought to the clinic with presenting complaints of mild fever and a rash mainly on the trunk with some lesions in the mouth. Rash was associated with pruritis and itching.
The appearance of rash is shown in the picture below:

The rash is in various stages including papules, vesicles and crusting that has appeared in crops.

1. What is the most probable diagnosis?
2. Which drugs are contraindicated in it and why?
3. Which complications can occur in this disease?
4. Which drug can help, if given in early phase of disease?
5. What can be done, if an un vaccinated adolescent comes in contact with this patient?

Answers And Discussion:


1. What is the most probable diagnosis?

Answer: A rash that is demonstrating various stages as papules, vesicles, crusting in the same patient at one time, coming in crops, mainly affecting the trunk, affecting the skin and mucous membrane and few of its lesions showing umbilication is very much suggestive of varicella or chickenpox.
It is a common viral infection caused by varicella zoster virus that is transmitted as a droplet infection. It presents with a rash and an enanthem (mucosal lesions) after an incubation period of     10 14 days. It is a mild disease of children. It is infective from the prodromal phase till the formation of crusts.
Clinical Features: Skin lesions are intensely pruritic and appear in crops. They begin as erythematous macules that rapidly turn into papules and vesicles. All stages of the rash may be seen simultaneously in a patient hence called polymorphic. Initial vesicles have a clear fluid and are surrounded by an erythematous halo so resemble “dew drop on a rose petal”. Later these vesicles develop an
umbilication and they turn into pustules.
It mainly affects the trunk with minimal affection of the face, extremities or mucosae. In most cases, it is a self limiting infection.
Varicella is infective 1 day before onset of rash to crusting of lesions which is usually 6 days after onset of rash.

2. Which drugs are contraindicated in it and why?

Answer: Aspirin should not be used in varicella else it may cause Reye’s syndrome. Similarly, use of steroids can increase its intensity and worsen the situation. It may result in fulminant type of chickenpox that may prove to be lethal. So, both these drugs should be strictly avoided in varicella.

3. Which complications can occur in this disease?

Answer: Secondary bacterial infection of the skin is its most common complication. Other complications that may occur are:

• thrombocytopenia, 
• varicella pneumonia, 
• Reye syndrome, 
• encephalitis and 
• Guillain-Barré syndrome

4. Which drug can help, if given in early phase of disease?

Answer: Antiviral therapy with acyclovir 20 mg/kg if begun within 24 hours of appearance of rash, may modify the course of disease and make it milder.

Ordinarily, patients require only symptomatic therapy as antihistamines for pruritis, paracetamol to control fever and antibiotics for secondary bacterial infection. 

Adults have a severe disease so may require antiviral therapy. Antiviral therapy with acyclovir 20 mg/kg (maximum 800 mg) is recommended 5 times a day for 4 days in neonates, immunocompromised host (as those suffering from leukemia, AIDS or nephrotic syndrome or those

on steroids or chemotherapeutic agents), hemorrhagic, gangrenous and ulcerative lesions and with complications as encephalitis, Reye’s syndrome, pneumonitis or cerebellar ataxia. In severe cases acyclovir may be administered intravenously. It should be given as early as possible. 

5. What can be done, if an un vaccinated adolescent comes in contact with this patient?

Answer: If an unvaccinated adolescent comes in contact with this patient then varicella vaccine can be administered. Its efficacy is 90% if administered within 3 days and 70% if administered within 5 days of exposure.