Treatment for chickenpox - PART-III

 

 

For most children

Treatment is mainly aimed at easing symptoms and trying to make your child as comfortable as possible whilst the immune system deals with the virus.

 

• Advice on dealing with a high temperature (fever) is detailed below.
• A soothing cream (emollient) may help the itch. Calamine lotion is the one most used, although it is not known how effective it is.
• A sedating antihistamine (in a tablet or liquid medicine) may help with sleep if itch is a problem. This can be used in children over 1 year old. Give a dose at bedtime. You can buy these at pharmacies or get them on prescription. Chlorphenamine (Piriton®) is the one most used. It can also be helpful for itch during the daytime but may cause some sleepiness as a side-effect.
• Keep fingernails cut short to stop deep scratching.
• Dress children comfortably so they are not cold or overheated. Use cool smooth fabrics such as cotton.

 

Dealing with a fever:

A fever commonly occurs with chickenpox, and may make your child feel uncomfortable and irritable. The following are things that you can do that may bring the temperature down and make your child feel more comfortable:

 

ü  You can give paracetamol to lower a temperature. You can buy paracetamol in liquid form, or as melt-in-the-mouth tablets, for children. It comes in various brand names. The dose for each age is given with the medicine packet. 

Note - 01 : paracetamol does not treat the cause of the fever. It merely helps to ease discomfort. It also eases headaches, and aches and pains. You do not need to use paracetamol if your child is comfortable and not distressed by the fever, aches or pains.

Note - 02 : ibuprofen has been used with paracetamol in the past. The National Institute for Health and Care Excellence (NICE) has recommended that ibuprofen no longer be used for chickenpox. This is because some studies suggested that there may be an association with more severe skin reactions if ibuprofen is used for chickenpox. While more evidence is awaited, the advice is to avoid ibuprofen in this situation.

 ü  Take extra layers of clothes off your child if the room is normal room temperature. It is wrong to wrap up a feverish child. The aim is to prevent overheating or shivering.

 ü  Give lots to drink. This helps to prevent a lack of fluid in the body (dehydration). You might find that a child is more willing to have a good drink if they are not so irritable. So, if they are not keen to drink, it may help to give some paracetamol first. Then, try the child with drinks half an hour or so later when his/her temperature is likely to have come down.

 

Do not cold-sponge a child who has a fever. This used to be popular, but it is now not advised. This is because the blood vessels under the skin become narrower (constrict) if the water is too cold. This reduces heat loss and can trap heat in deeper parts of the body. The child may then get worse. Many children also find cold-sponging uncomfortable.

 

Some people use a fan to cool a child. Again, this may not be a good idea if the fanned air is too cold. However, a gentle flow of air in a room which is room temperature may be helpful. Perhaps just open the window or use a fan on the other side of the room to keep the air circulating.

 

Lifestyle and home remedies

For most mild cases of chickenpox, resting, staying home, and employing some home remedies or over-the-counter products to ease the itching and discomfort are all that’s needed. Adults and children at risk of complications may be prescribed antiviral drugs to reduce the severity and duration of chickenpox symptoms.

 

To help ease the symptoms of an uncomplicated case of chickenpox, follow these self-care measures.

 

Avoid scratching

Scratching can cause scarring, slow healing and increase the risk that the sores will become infected. If your child can't stop scratching:

• Put gloves on his or her hands, especially at night
• Trim his or her fingernails

Relieve the itch and other symptoms

The chickenpox rash can be very itchy, and broken vesicles sometimes sting. These discomforts, along with fever, headache and fatigue, can make anyone miserable.

 

For relief, try:

ü  A cool bath with added baking soda, aluminum sulfate and calcium acetate (Domeboro, others), uncooked oatmeal or colloidal oatmeal — a finely ground oatmeal that is made for soaking.

ü  Calamine lotion dabbed on the spots.

ü  A soft, bland diet if chickenpox sores develop in the mouth.

ü  Antihistamines such as diphenhydramine (Benadryl, others) for itching. Check with your doctor to make sure your child can safely take antihistamines.

ü  Acetaminophen (Tylenol, others) for a mild fever.

 

If fever lasts longer than four days and is higher than 102 deg. Celsius , call your doctor. And don't give aspirin to children and teenagers who have chickenpox because it can lead to a serious condition called Reye's syndrome.

 

Talk with your doctor before giving any type of nonsteroidal anti-inflammatory drug (NSAID) — such as ibuprofen (Advil, Motrin IB, others) — to someone who has chickenpox. Some studies suggest this type of medication may lead to skin infections or tissue damage. 

 

For special at-risk groups

Some children have a higher risk of developing complications from chickenpox. In addition to the above treatments, they may need extra treatment such as aciclovir (an antiviral medicine) or vaccination. If your child has not already had chickenpox and is in one in the following groups, you should see a Medical Practitioner urgently if they have contact with chickenpox, or have symptoms of it.

 

• Children (babies) less than 1 month old.
• Children with a poor immune system. For example, children with leukaemia, immune diseases or HIV/AIDS.
• Children taking certain medication such as steroids, immune-suppressing medication or chemotherapy.
• Children with severe heart or lung disease.
• Children with severe skin conditions.

 

Antiviral medication is also used for adults and teenagers who develop chickenpox, as they too have a higher risk of complications. However, antiviral medication is not normally advised for healthy children aged over 1 month and under 12 years who develop chickenpox.

 

Is chickenpox infectious?

A person with chickenpox is very infectious. The virus spreads in the air from person to person. For example, if you have not already had chickenpox, you stand a good chance of catching it if:

• You are in the same room as someone with chickenpox for more than 15 minutes; or
• You have any face-to-face contact with someone with chickenpox, such as a conversation. 

Nine in ten people who have not had chickenpox would catch it after being exposed in this way. It takes between 7 and 21 days (most commonly 10-14 days) to develop symptoms after catching the virus (the incubation period).

  

Medication Options

Most of the time, no medications are needed to treat chickenpox. If you or your child has severe itching, talk to your doctor about taking an antihistamine to help control it.

If you or your child has a fever due to chickenpox, taking acetaminophen (Tylenol) can help lower it.

 

For people with an elevated risk of complications from chickenpox, doctors often prescribe an antiviral drug, such as acyclovir (Zovirax, Sitavig).

 

Other antiviral drugs that may be options for some people include valacyclovir (Valtrex) and famciclovir (Famvir).

 

Pathophysiology and Diagnosis of Varicella Zoster Virus (VZV) - PART-II

 

DESCRIPTION:

The highly contagious illness varicella, sometimes known as chickenpox, is caused by an early infection with the Varicella Zoster Virus (VZV). The disease results in a recognizable skin rash that grows into tiny, uncomfortable blisters before eventually scabbing over. Typically, it begins on the chest, back, and face. It then spreads all across the body. The disease often worsens more quickly in adults than in kids. When an infected individual coughs or sneezes, the airborne illness known as chickenpox can readily spread from one person to another. After an incubation period of 10 to 21 days, the characteristic rash appears. It may spread from one to two days before the rash appears until all lesions have crusted over. It might spread if someone touched the blisters. People with shingles may spread chickenpox to those who aren't immune by touching the blisters. However, in unusual cases, Polymerase Chain Reaction (PCR) testing of the blister fluid or scabs may be required to confirm the diagnosis. Usually, the condition can be diagnosed based on the presenting symptom. Antibodies can be checked to see if a person is immune. Usually, a person only gets chickenpox once. Despite the possibility of reinfection, the majority of the time there are no symptoms. 

Symptoms and signs:

In both adolescents and adults, the early (prodromal) symptoms include nausea, loss of appetite, painful muscles, and headache. After this, the usual rash or oral sores, sluggishness, and low grade fever that signal the disease's presence appear. On rare occasions, the disease's oral symptoms (enanthem) may manifest before the external rash. Children frequently develop a rash or mouth spots as their first symptoms of an illness. In children, prodromal signs are rare. The initial signs of the rash are small red dots that appear on the face, scalp, torso, upper arms, and legs. Small bumps, blisters, and pustules develop over the period of 10–12 hours, and are then followed by umbilication and the formation of scabs. 

Pathophysiology:

After being exposed to the Varicella Zoster Virus (VZV), healthy children create immunoglobulin G (IgG), immunoglobulin M (IgM), and immunoglobulin A (IgA) antibodies. IgG antibodies last a lifetime and offer immunity. Cell-mediated immune responses must cooperate in order to reduce the intensity and length of the primary varicella infection. After primary infection, it is believed that the Varicella Zoster Virus (VZV) spreads from adjacent sensory nerves to mucosal and epidermal sores. The Varicella Zoster Virus (VZV) then remains latent in the dorsal ganglion cells of the sensory nerves. The reactivation of the varicella zoster virus causes the clinically distinct syndromes of herpes zoster (shingles), postherpetic neuralgia, and sporadically Ramsay Hunt syndrome type II (VZV). Varicella zoster can damage the arteries in the neck and head and cause stroke in infancy or after a protracted latency period. 

Diagnosis and treatment:

Examining the fluid within the vesicles of the rash or testing blood for signs of an acute immune response can also help confirm the diagnosis. Using a Tzanck smear or a direct fluorescent antibody test, vesicular fluid can be analysed. Additionally, the fluid can be "cultured," which entails making an effort to develop the virus from a sample of the fluid. Blood tests can be performed to determine an acute infection response (IgM) or a prior infection and subsequent immunity (IgG). It is recommended to wait five weeks after the first maternal infection before utilising ultrasonography to diagnose foetal varicella. It is also possible to test the mother's amniotic fluid for PCR (DNA), although this approach has a higher risk of spontaneous abortion than it does of foetal varicella syndrome development. 

Children: Children with chickenpox are treated for the symptoms while the immune system fights the infection. Because they are more likely than adults to scratch their blisters more deeply, children under the age of 12 should have their fingernails clipped short and kept clean. 

Epidemiology:

It is unclear where the word "chickenpox" came from, however it could have something to do with how mild the illness was. On the basis of the vesicles' likeness to chickpeas or the rash's resemblance to chicken pecks, it has been suggested that it originated from chickpeas. Other theories include the term "chicken pox" (meaning "kid pox"), a misspelling of "itching pox," or the hypothesis that poultry may have carried the disease in the past. The designation was made, according to Samuel Johnson, "from its being of no very great risk." 

Source: Department of Pulmonary and Critical Medicine, Oregon Health and Sciences University, Portland, USA

Chickenpox (varicella) Diagnosis, Pathophysiology and Treatment - PART-I

 

Chickenpox is an infection caused by the varicella-zoster virus. Most children have chickenpox at some stage. Most commonly, children get chickenpox before the age of 10 years. The immune system makes proteins called antibodies during the infection. These fight the virus and then provide lifelong protection against it (immunity). Therefore, it is uncommon to have more than one bout of chickenpox in your lifetime.

Cause:

The varicella-zoster virus may be spread through the air when an infected person coughs or sneezes or by direct contact with the blisters (lesions) of someone infected with chickenpox or shingles.

The risk of getting chickenpox is higher for people who have had contact with an infected person, are under 12 years old, have a weakened immune system, or who work or spend time in a school or daycare facility.

Once someone is infected, the virus usually incubates for 14 to 16 days before a rash appears, although incubation can last from 10 days to 21 days. There are no symptoms during incubation and a person doesn't become contagious until 1 to 2 days before the rash appears. The person remains contagious until all the blisters have dried and scabs have formed. 

To prevent the spread of the virus to others, people who have or are suspected to have chickenpox should avoid public places, such as school, until all blisters have scabbed over. 

Chickenpox Blisters: 

Symptoms:

The itchy blister rash caused by chickenpox infection appears 10 to 21 days after exposure to the virus and usually lasts about five to 10 days. Other signs and symptoms, which may appear one to two days before the rash, include:

• Fever
• Loss of appetite or feeding problems to child
• Headache
• Tiredness and a general feeling of being unwell (malaise)

 

Once the chickenpox rash appears, it goes through three phases:

• Raised pink or red bumps (papules), which break out over several days
• Small fluid-filled blisters (vesicles), which form in about one day and then break and leak
• Crusts and scabs, which cover the broken blisters and take several more days to heal

New bumps continue to appear for several days, so you may have all three stages of the rash — bumps, blisters and scabbed lesions — at the same time.

You can spread the virus to other people for up to 48 hours before the rash appears, and the virus remains contagious until all broken blisters have crusted over. 

The disease is generally mild in healthy children. In severe cases, the rash can cover the entire body, and lesions may form in the throat, eyes, and mucous membranes of the urethra, anus and vagina.

 Chickenpox Scabbing: 

 

Some children feel quite unwell for a few days. Others appear only mildly ill. Most are much better within a week. The blisters dry up and scab. They gradually fade but may take up to two weeks to go completely. 

Most of the time, children with chickenpox recover fully and have no complications. Uncommonly, one or more of the following complications can occur.

 

• The spots do not usually scar unless they are badly scratched.
• Some spots become infected with germs (bacteria) in some cases. This is the most common complication in children. If this occurs, the surrounding skin becomes red and sore. Antibiotics in the form of creams or medicine may then be needed.
• Inflammation of the lung (pneumonia) and inflammation of the brain (encephalitis) are rare complications.
• Vary rarely, other serious complications develop. For example: 

ü  Reye's syndrome. (A very rare condition with brain and liver problems).

ü  Inflammation of the heart muscle (myocarditis).

ü  Kidney inflammation (glomerulonephritis).

ü  Appendicitis.

ü  Ataxia (problems co-ordinating movements).

ü  Inflammation of the pancreas (pancreatitis).

ü  Henoch-Schönlein purpura (a condition that can affect the kidneys).

ü  Inflammation of the testes (orchitis).

ü  Inflammation of the joints (arthritis).

ü  Inflammation of various parts of the eye.

Therefore, although serious complications are rare, it is best to be watchful. Consult with Medical Practitioner if your child develops any worrying symptoms that you are unsure about such as:

 

• Breathing problems.
• Weakness such as a child becoming wobbly on his/her feet.
• Drowsiness.
• Fits (convulsions).
• Pains or headaches which become worse despite paracetamol.
• Being unable to take fluids, due to a severe rash in the mouth.
• A severe rash, or a rash which bruises or bleeds into the skin (haemorrhagic rash).
• Becoming generally more and more unwell.

 Shingles

Shingles is caused by the same virus that causes chickenpox and is a very delayed complication of chickenpox. Anyone who has had chickenpox in the past may develop shingles. Shingles is an infection of a nerve and the area of skin supplied by the nerve. It causes a rash and pain in a local band-like area along the affected nerve. About 1 in 5 people have shingles at some time in their lives. It can occur at any age, but it is most common in people over the age of 50.

 

The reason why shingles may occur is because the virus does not completely go after you have chickenpox. Some virus particles remain inactive in the nerve roots next to your spinal cord. They do no harm there and cause no symptoms. For reasons that are not clear, the virus may begin to multiply again (reactivate). This is often years later. The reactivated virus travels along the nerve to the skin to cause shingles.

Note: you can catch chickenpox from being exposed to a person with shingles if you have not had chickenpox yourself. However, you cannot catch shingles from a person with chickenpox, or catch shingles from a person with shingles.

Heart Infections

 The term heart infection may be used to describe conditions such as endocarditis or myocarditis. Symptoms of a heart infection include:

• chest pain
• chest congestion or coughing
• fever
• chills
• skin rash

What is endocarditis?

Endocarditis is inflammation of our heart’s inner lining, called the endocardium. It’s usually caused by bacteria. When the inflammation is caused by infection, the condition is called infective endocarditis. Endocarditis is uncommon in people with healthy hearts.

Symptoms of endocarditis

The symptoms of endocarditis aren’t always severe, and they may develop slowly over time. In the early stages of endocarditis, the symptoms are similar to many other illnesses. This is why many cases go undiagnosed.

 

Many of the symptoms are similar to cases of the flu or other infections, such as pneumonia. However, some people experience severe symptoms that appear suddenly. These symptoms may be due to inflammation or the associated damage it causes.

Common symptoms of endocarditis include:

• heart murmur, which is an abnormal heart sound of turbulent blood flow through the heart
• pale skin
• fever or chills
• night sweats
• muscle or joint pain
• nausea or decreased appetite
• a full feeling in the upper left part of your abdomen
• unintentional weight loss
• swollen feet, legs, or abdomen
• cough or shortness of breath

Less common symptoms of endocarditis include:

• blood in your urine
• weight loss
• an enlarged spleen, which may be tender to touch

Changes in the skin may also occur, including:

• tender red or purple spots below the skin of fingers or toes
• tiny red or purple spots from blood cells that leaked out of ruptured capillary vessels, which usually appear on the whites of the eyes, inside the cheeks, on the roof of the mouth, or on the chest

 

The signs and symptoms of infectious endocarditis vary greatly from person to person. They can change over time, and they depend on the cause of your infection, heart health, and how long the infection has been present. If you have a history of heart problems, heart surgery, or prior endocarditis, you should contact your doctor immediately if you have any of these symptoms. It’s especially important to contact your doctor if you have a constant fever that will not break or you’re unusually tired and don’t know why.

 

Causes of endocarditis

The main cause of endocarditis is an overgrowth of bacteria. Although these bacteria normally live on the inside or outside surfaces of our body, we might bring them inside to our bloodstream by eating or drinking.

 

Bacteria could also enter through cuts in our skin or oral cavity. Our immune system normally fights off germs before they cause a problem, but this process fails in some people.

 

In the case of infective endocarditis, the germs travel through your bloodstream and into your heart, where they multiply and cause inflammation. Endocarditis can also be caused by fungi or other germs.

 

Eating and drinking aren’t the only ways that germs can enter our body. They can also get into our bloodstream through:

 

• brushing our teeth
• having poor oral hygiene or gum disease
• having a dental procedure that cuts our gums
• contracting a sexually transmitted disease
• using a contaminated needle
• through an indwelling urinary catheter or intravenous catheter

What is myocarditis?

Myocarditis is a disease marked by the inflammation of the heart muscle known as the myocardium — the muscular layer of the heart wall. This muscle is responsible for contracting and relaxing to pump blood in and out of the heart and to the rest of the body.

 

When this muscle becomes inflamed, its ability to pump blood becomes less effective. This causes problems like an abnormal heartbeat, chest pain, or trouble breathing. In extreme cases, it can cause blood clots leading to a heart attack or stroke, damage to the heart with heart failure, or death.

 

Normally, inflammation is a bodily response to any sort of wound or infection. Imagine when you cut your finger: within a short time, the tissue around the cut swells up and turns red, which are classic signs of inflammation. The immune system in our body is producing special cells to rush to the site of the wound and implement repairs.

 

But sometimes the immune system or another cause of inflammation leads to myocarditis.

 

Causes myocarditis

In most of the cases, the exact cause of myocarditis is not found. When the cause of myocarditis is found, it’s usually an infection that has made its way to the heart muscle, such as a viral infection (the most common) or a bacterial, parasitic, or fungal infection.

 

As the infection tries to take hold, the immune system fights back, trying to get rid of the disease. This results in an inflammatory response that may weaken heart muscle tissue. Some autoimmune diseases, like lupus (SLE), can cause the immune system to turn against the heart, resulting in inflammation and myocardial damage.

 

It’s often difficult to determine exactly what’s causing the myocarditis, but potential culprits include the following causes.

 

Viruses

Viruses are one of the most common causes of infectious myocarditis. The most common viruses to cause myocarditis include Coxsackievirus group B (an enterovirus), Human Herpes Virus 6, and Parvovirus B19 (which causes fifth disease).

 

Other possibilities include echoviruses (known to cause gastrointestinal infection), Epstein-Barr virus (causes infectious mononucleosis), and Rubella virus (causes German measles).

 

Bacteria

Myocarditis can also result from infection with Staphylococcus aureus or Corynebacterium diptheriae. Staphylococcus aureus is the bacterium that can cause impetigo and be a methicillin resistant strain (MRSA). Corynebacterium diptheriae is the bacterium that causes diphtheria, an acute infection that destroys tonsils and throat cells.

 

Fungi

Yeast infections, molds, and other fungi can sometimes cause myocarditis.

Parasites

Parasites are microorganisms that live off of other organisms to survive. They can also cause myocarditis. This is rare in the society but more commonly seen in Central and South America (where the parasite Trypanosoma cruzi causes a condition known as Chagas disease).

 

Autoimmune diseases

Autoimmune diseases that cause inflammation in other parts of the body, like rheumatoid arthritis or SLE, can also sometimes cause myocarditis.

 

Symptoms of Myocarditis

The dangerous thing about myocarditis is that it can affect anyone, occur at any age, and may proceed without displaying any symptoms.

 

If symptoms do develop, they often resemble those symptoms one might experience with the flu, such as:

• fatigue
• shortness of breath
• fever
• joint pain
• lower extremity swelling
• achy feeling in the chest

Many times, myocarditis may subside on its own without treatment, much like a cut on your finger eventually heals. Even some cases that go on for a long time may never create sudden symptoms of heart failure.

 

But, secretly, they may cause damage to the heart muscle where the heart failure symptoms slowly appear over time. In other instances, the heart may be faster at revealing its struggles, with symptoms like chest pain, shortness of breath, heart palpitations, and heart failure.

 

 

ERRATIC HEART BEAT (ARRHYTHMIA)

 

Arrhythmias can occur when the electrical impulses that coordinate your heart rhythm do not travel normally. This causes the heart to beat too fast, too slow, or with an irregular rhythm.

Almost everyone has felt their heart "skip" or “flutter” a beat or two, and speed up in times of fear or excitement or during exercise. 

Too much caffeine and certain medications also can cause heart palpitations (heart racing or fluttering) in some people. These types of arrhythmias are generally harmless.

While most arrhythmias are harmless, some can be serious or even life threatening. When a heartbeat is too fast, too slow or irregular, the heart may not be able to pump enough blood to the body. 

Arrhythmias can be associated with serious symptoms that can affect your ability to function. Lack of blood flow can damage the brain, heart and other organs.

If irregular heartbeats are frequent or chronic, they can be very serious. Troublesome arrhythmias can be made worse, or can be caused by a weak or damaged heart. 

Uncontrolled rapid arrhythmias can result in heart weakness over time.

Types of Arr​​hythmias

There are two major types of arrhythmia:

·       Tachycardia, where the heart beat is too fast - more than 100 beats per minute

•       Bradycardia, where the heartbeat is to slow – less than 60 beats per minute.

Arrhythmias are identified by where they originate in the heart and whether they cause the heart to beat slow or fast.

• Arrhythmias that start in the atria are called atrial or supraventricular (above the ventricles) arrhythmias.
• Rapid heart rhythms originating in the atria include atrial fibrillation, atrial flutter, and supraventricular tachycardia.
• Arrhythmias that start in the ventricle include ventricular tachycardia and ventricular fibrillation. These are serious, often life-threatening arrhythmias since the ventricles do most of the pumping. Ventricular fibrillation is the most common cause of sudden cardiac arrest (SCA) and is fatal if not treated within a few minutes.
• Slow heart rhythms occur when the hearts normal pacemaker fails or when there is a conduction block within the conduction pathways.

 Symptoms of Arrhythmia

Arrhythmias may not cause any signs or symptoms. In fact, your doctor might find you have an arrhythmia during a routine examination. Symptoms of a heart arrhythmia include:

• A “fluttering” sensation in your chest
• A racing heartbeat (tachycardia)
• A slow heartbeat (bradycardia)
• Chest pain
• Shortness of breath
• Light-headedness
• Dizziness
• Fainting (syncope) or near fainting
• Fatigue

Causes of Arrhythmia

Risk factors and causes of heart arrhythmias include:

• Heart disease
• Electrolyte imbalances in your blood
• Structural abnormalities of the heart
• Infection
• Abnormal electrical pathways
• Medications

When it comes to arrhythmia it’s always better to err on the side of caution. If you have a concern about an irregular heartbeat, you should contact your doctor.