Bacterial complications of primary varicella in children

Antibiotic chemoprophylaxis for close contacts of invasive group A streptococcus in community settings: Evidence review

OBJECTIVES

Revised UK guidelines for the management of contacts of invasive group A Streptococcus (iGAS) infection in community settings were published in December 2022. We present the findings of a narrative review which informed the public health recommendations around the provision of antibiotic chemoprophylaxis detailed in the updated guidelines.

METHODS

We conducted a literature review of studies reporting the risk of iGAS infection associated with specific risk factors.

RESULTS

There was strong epidemiological evidence for an increased risk of iGAS infection in contacts who are older individuals, post-partum women, neonates and individuals with chickenpox infection; evidence on the impact of influenza co-infection, injecting drug use or being homeless in increasing risk of iGAS infection was less robust.

CONCLUSIONS

The guidelines made recommendations to offer chemoprophylaxis to close contacts of iGAS cases who are aged ≥75 years, pregnant ≥37 weeks gestation, post-partum, neonates or those with a recent history of, or current chickenpox infection. Systematic data collection evaluating the use of chemoprophylaxis and other control measures is recommended.

Treatment outcomes and their predictors in children hospitalized with varicella complicated by bacterial superinfections after pandemic of COVID-19 - a retrospective multicenter analysis of real-life data in Poland

PURPOSE

The aim of this study was to analyze treatment outcomes and their predictors in children hospitalized due to varicella complicated by bacterial superinfections after pandemic of COVID-19.

METHODS

This retrospective study analyzed data collected in a multicenter, nationwide, observational database dedicated for children aged 0-17 years hospitalized due to bacterial complications of varicella in 9 Polish tertiary healthcare inpatient centers. The primary endpoint of this study was the treatment outcome established after the end of hospital management assessed at a 4-point scale. The secondary endpoint was defined as the necessity of surgical intervention.

RESULTS

There were 458 patients with a median age of 4 (IQR 2-6) years. After the completed treatment, 319 (69%) participants were found fully recovered; 132 (29%) had transient complications; 2 (0.5%) had persistent complications; and 1 child (0.5%) died. Multivariate analysis revealed that implementation of ibuprofen in pre-treatment management of a child with varicella was associated with a 4.07-fold (2.50-6.60) increase in risk of complications after the treatment and it was associated with 2.87 times (1.39-5.89) higher risk of surgical intervention necessity. For other pre-hospital interventions (implementation of acyclovir, antibiotics or antihistaminics) no significant impact was observed. GAS infection increased the necessity of surgical intervention by 7.51 (3.64-15.49) times.

CONCLUSIONS

One-third of patients treated for bacterial complications of varicella have post-treatment complications, most of them transient. GAS infection increases the need for surgical intervention. The use of ibuprofen in the treatment of varicella significantly increases the risk of complications and the need for surgical intervention.

Varicella mimicking complications of acute rhinosinusitis in an infant

Varicella is the manifestation of primary infection with the varicella-zoster virus, mainly affecting preschool and school-aged children. The children suffer from a generalised, vesicular rash and fever. Despite the infection's typically non-threatening course, a variety of severe complications have been described.The authors present the case of a female infant suffering from varicella and developing preseptal cellulitis with a frontal abscess while being treated with intravenous antibiotics. Otorhinolaryngology consultation was sought since the clinical image was highly suggestive for sinusitis complications, namely orbital cellulitis and frontal bone osteomyelitis (Pott's puffy tumour). However, the child was below the age of frontal sinus development and there was no other apparent sign of sinonasal involvement. Ultrasonography revealed a mid-frontal collection without signs of abscess formation preseptally or postseptally, leading to the diagnosis of cutaneous superinfection of varicella lesions. The frontal abscess was drained, and the child fully recovered under antibiotic treatment.

Diagnostic Methods and Management Strategies of Herpes Simplex and Herpes Zoster Infections

Herpesviruses are medium-sized double-stranded DNA viruses. Of more than 80 herpesviruses identified, only 9 human herpesviruses have been found to cause infection in humans. These include herpes simplex viruses 1 and 2 (HSV-1 and HSV-2), varicella-zoster virus (VZV), human cyto-megalovirus (HCMV), Epstein-Barr virus (EBV), and human herpesvirus (HHV-6A, HHV-6B, HHV-7, HHV-8). HSV-1, HSV-2, and VZV can be problematic given their characteristic neurotropism which is the ability to invade via fusion of its plasma membrane and reside within neural tissue. HSV and VZV primarily infect mucocutaneous surfaces and remain latent in the dorsal root ganglia for a host's entire life. Reactivation causes either asymptomatic shedding of virus or clinical manifestation of vesicular lesions. The clinical presentation is influenced by the portal of entry, the immune status of the host, and whether the infection is primary or recurrent. Affecting 60% to 95% of adults, herpesvirus-associated infections include gingivostomatitis, orofacial and genital herpes,and primary varicella and herpes zoster. Symptomatology, treatment, and potential complications vary based on primary and recurrent infections as well as the patient's immune status.

Economic Evaluation of Universal Varicella Vaccination in Mexico

BACKGROUND

Universal varicella vaccination has proven to be cost-effective (CE) in countries where implemented. However, this has not been evaluated for Mexico.

METHODS

The yearly disease burden (varicella cases/deaths, outpatient visits, and hospitalizations) was derived from Mexican seroprevalence data adjusted to the 2020 population. The yearly economic burden was calculated by combining disease with Mexican unit cost data from both health care and societal perspectives. Four different vaccination strategies were evaluated: (1) 1 dose of varicella vaccine at 1 year old; (2) 2 doses at 1 and 6 years; (3) 1 dose of varicella vaccine at 1 year, and quadrivalent measles-mumps-rubella-varicella vaccine at 6 years; (4) 2 doses of measles-mumps-rubella-varicella vaccine at 1 and 6 years. We developed an economic model for each vaccination strategy where 20 consecutive birth cohorts were simulated. Vaccination impact (number of avoided cases/deaths) was evaluated for a 20-year follow-up period based on vaccine effectiveness (87% and 97.4% for 1 and 2 doses), and assuming a 95% coverage. We estimated annual costs saved, incremental cost-effectiveness ratio, and costs per life year gained.

RESULTS

Avoided cases during the 20-year follow-up with 1, and 2 doses were 20,570,722 and 23,029,751, respectively. Strategies 1 and 2 were found to be cost saving, and strategy 3 to be CE. Strategy 4 was not CE. Strategies 1 and 2 would allow saving annually $53.16 and $34.41 million USD, respectively, to the Mexican society.

CONCLUSIONS

Universal varicella vaccination, using 1 dose or 2 doses, would result in a cost-beneficial and CE public health intervention in Mexico.

Varicella Zoster Virus Impairs Expression of the Nonclassical Major Histocompatibility Complex Class I-Related Gene Protein (MR1)

The antigen presentation molecule MR1 (major histocompatibility complex, class I-related) presents ligands derived from the riboflavin (vitamin B) synthesis pathway, which is not present in mammalian species or viruses, to mucosal-associated invariant T (MAIT) cells. In this study, we demonstrate that varicella zoster virus (VZV) profoundly suppresses MR1 expression. We show that VZV targets the intracellular reservoir of immature MR1 for degradation, while preexisting, ligand-bound cell surface MR1 is protected from such targeting, thereby highlighting an intricate temporal relationship between infection and ligand availability. We also identify VZV open reading frame (ORF) 66 as functioning to suppress MR1 expression when this viral protein is expressed during transient transfection, but this is not apparent during infection with a VZV mutant virus lacking ORF66 expression. This indicates that VZV is likely to encode multiple viral genes that target MR1. Overall, we identify an immunomodulatory function of VZV whereby infection suppresses the MR1 biosynthesis pathway.

Pediatric Group A streptococcal spinal epidural abscess presenting with recurrent symptoms of viral illness: An operative case report

Background

Spinal epidural abscess (SEA) in children is a rare condition with dangerous sequelae, and with only 22 other cases reported in the literature, treatment algorithms are poorly understood. Quick identification of the classic tried of sepsis, back pain and neurological deficit is critical. Source identification difficult and often cannot be identified. Reported pathogens include varicella-zoster virus, S. aureus, and S pyogenes.

Case description

We report a case of spontaneous pediatric SEA in a 22-month old female without obvious neurologic deficit, who underwent a T10-11 decompressive laminotomy and evacuation of abscess and subsequent 3-week course of intravenous ceftriaxone for culture positive S. pyogenes

Outcome

The patient showed marked improvement in symptoms after decompression. 5 weeks postoperatively after transitioning from intravenous ceftriaxone to oral ceftin, the patient redeveloped a deep space infection and was taken back for a repeat debridement. The cultures from this procedure were negative and the patient was discharged on oral clindamycin.

Conclusions

Pediatric spontaneous SEA is a rare condition and early diagnosis and surgical intervention if indicated can prevent dangerous sequelae. Further studies into the surgical indications for decompression will aid in algorithmic decision making.

Diagnosis and management of community-acquired pneumonia in children: South African Thoracic Society guidelines

BACKGROUND

Pneumonia remains a major cause of morbidity and mortality amongst South African children. More comprehensive immunisation regimens, strengthening of HIV programmes, improvement in socioeconomic conditions and new preventive strategies have impacted on the epidemiology of pneumonia. Furthermore, sensitive diagnostic tests and better sampling methods in young children improve aetiological diagnosis.

OBJECTIVES

To produce revised guidelines for pneumonia in South African children under 5 years of age.

METHODS

The Paediatric Assembly of the South African Thoracic Society and the National Institute for Communicable Diseases established seven expert subgroups to revise existing South African guidelines focusing on: (i) epidemiology; (ii) aetiology; (iii) diagnosis; (iv) antibiotic management and supportive therapy; (v) management in intensive care; (vi) prevention; and (vii) considerations in HIV-infected or HIVexposed, uninfected (HEU) children. Each subgroup reviewed the published evidence in their area; in the absence of evidence, expert opinion was accepted. Evidence was graded using the British Thoracic Society (BTS) grading system. Sections were synthesized into an overall guideline which underwent peer review and revision.

RECOMMENDATIONS

Recommendations include a diagnostic approach, investigations, management and preventive strategies. Specific recommendations for HIV infected and HEU children are provided.

VALIDATION

The guideline is based on available published evidence supplemented by the consensus opinion of SA paediatric experts. Recommendations are consistent with those in published international guidelines.

Epidemiological Situation of Necrotizing Fasciitis and Factors in Thailand and Factors Associated with Its Morbidity and Mortality, 2014-2018

INTRODUCTION

Necrotizing fasciitis (NF) is a rare skin and soft-tissue bacterial infection with high morbidity and mortality. Knowledge about the prevalence and incidence of NF in Thailand is quite sparse. The objective of this study was to determine the prevalence of NF in Thailand and factors that may be potentially associated with NF morbidity and mortality.

METHODS

A cross-sectional study using secondary data from Thailand's national health databases between 2014 and 2018 was conducted. Descriptive statistics using median and percentage formats were used. This was complemented by multivariable logistic regression to determine the association between various factors (such as age and underlying diseases) with NF morbidity and mortality. Univariate spatial data analysis was exercised to identify the geographical hot spots in which the disease appeared.

RESULTS

During 2014-2018, we found 90,683 NF cases. About 4.86% of the cases died. The median age for all cases was 59.39 years old. The annual incidence of NF demonstrated an upward trend (from 26.08 per 100,000 population in 2014 to 32.64 per 100,000 population in 2018). The monthly incidence was highest between May and August. A high incidence cluster (as indicated by local Moran's I) was found in the north-eastern region of Thailand. The most infected sites were on the ankles and feet (43.18%) with an amputation rate of 7.99% in all cases. Multivariable logistic regression indicated that the significant risk factor for amputation was a presence of underlying diseases, namely diabetes (OR 7.94, 95% CI 7.34-8.61). Risk factors for mortality included being elderly (OR 1.82, 95% CI 1.68-1.98) and a presence of underlying hypertension (OR 1.16, 95% CI 1.07-1.27), cirrhosis (OR 4.67, 95% CI 4.17-5.21), and malignancy (OR 1.88, 95% CI 1.55-2.26).

DISCUSSION AND CONCLUSION

As the elderly and those with chronic underlying diseases are likely to face non-preferable health outcomes from NF, healthcare providers should pay great attention to these groups of patients. Early and intensive treatment might be considered in these groups of patients. Further studies that aim to validate the volume of actual NF cases and reported NF cases are recommended.

Retropharyngeal abscess and mediastinitis as an uncommon complication of varicella infection

Varicella infection is one of the most common and contagious infection in children and could course with severe complications. We report the case of a 4-year-old patient derived to our hospital for suspicion of suppurative complication in the context of a varicella infection. A computerized tomographic scanning was performed, showing a large retropharyngeal abscess with mediastinitis. Complications of varicella are up to 2% of patients, but this is the first report of a retropharyngeal and mediastinal abscess in this context. In the face of clinical suspicion, early intervention is important through imaging, intravenous antibiotics and surgical drainage in necessary cases.

The clinical and economic burden of varicella in the Middle East: a systematic literature review

This systematic literature review was conducted to better understand the epidemiology and burden of varicella across the Middle East, gain insight into the evidence to support using universal varicella vaccination (UVV), and identify potential data gaps. Both epidemiology and economic data on the burden of varicella were limited and varied significantly. Most of the data focussed on varicella burden in the absence of a UVV program. In the absence of UVV, varicella incidence is increasing across this region with varicella infection associated with substantial morbidity. Although limited, data on the impact of vaccination at a population level indicated UVV programs reduce varicella incidence and hospitalizations, in line with global experience. Further research and action are needed to better understand varicella epidemiology in the Middle East, increase awareness and understanding in the region, and provide local data to support national public-health decisions regarding the implementation of UVV programs.

A severe case of Streptococcal pyogenes empyema following influenza A infection

BACKGROUND

Any immunological mechanisms induced by influenza virus could cause severe secondary bacterial superinfection such as those by Streptococcus pyogenes [group A streptococcus (GAS)], Streptococcus pneumoniae or Staphylococcus aureus. Over recent years, the frequency of pleural empyema has increased in children with influenza infection. We present a severe case of acute empyema caused by S.pyogenes after influenza A infection.

CASE PRESENTATION

A previously healthy 39-year old woman was diagnosed as influenza A and received oral Oseltamivir 75 mg twice daily for 5 days. She had no vaccination of influenza A. Although her influenza A infection improved, she complained of fever and cough to our institute. Chest radiography showed encapsulated pleural effusion of the left lung and pleural effusion which was consistent with acute empyema. Then, she was diagnosed as having acute empyema and was admitted to our institute. Streptococcus pyogenes was identified by pleural fluid culture on day 4. thus, MNZ was changed to clindamycin (CLDM) 600 mg three times a day. While thoracic drainage with intrapleural urokinase and combination antibiotic therapy of ceftriaxone and CLDM were performed, her general condition and chest radiographic findings were not improved. She received video-assisted thoracic debridement on day 10. After the operation, the antibiotic therapy was changed to ABPC 6 g daily iv. Due to good clinical course, the antibiotic therapy was switched to oral amoxicillin 500 mg three times daily on day 28. Then, she was discharged.

CONCLUSION

Influenza A virus infection could lead to severe GAS infection, while the latter can occur in otherwise healthy individual as well. Physician must consider the possibility of severe GAS infection after influenza A infection.

Overwhelming Streptococcus pyogenes sepsis in an elderly patient with septic arthritis

INTRODUCTION

The signs of Streptococcus pyogenes, group A streptococci (GAS) bacteremia are non-specific and patients can have wide presentations ranging from flu-like symptoms to life-threatening toxic-shock syndrome in just a few hours.

CASE PRESENTATION

We report a case of fulminant S. pyogenes sepsis in an elderly woman with septic arthritis and remarkable past medical history/risk factors. She was febrile, hypotensive and had a swollen and tender right knee. Multiple blood cultures and the synovial fluid culture yielded S. pyogenes. Despite adequate antimicrobial therapy with penicillin and clindamycin the patient succumbed to her infection within 4days of presentation in our hospital.

CONCLUSION

GAS remains penicillin sensitive most of the time but prompt appropriate antibiotic therapy is very crucial to survival.

Severe varicella-zoster virus pneumonia: a multicenter cohort study

BACKGROUND

Pneumonia is a dreaded complication of varicella-zoster virus (VZV) infection in adults; however, the data are limited. Our objective was to investigate the clinical features, management, and outcomes of critically ill patients with VZV-related community-acquired pneumonia (VZV-CAP).

METHODS

This was an observational study of patients with VZV-CAP admitted to 29 intensive care units (ICUs) from January 1996 to January 2015.

RESULTS

One hundred and two patients with VZV-CAP were included. Patients were young (age 39 years (interquartile range 32-51)) and 53 (52%) were immunocompromised. Time since respiratory symptom onset was 2 (1-3) days. There was a seasonal distribution of the disease, with more cases during spring and winter time. All but four patients presented with typical skin rash on ICU admission. Half the patients received mechanical ventilation within 1 (1-2) day following ICU admission (the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO₂/FiO₂) = 150 (80-284), 80% with acute respiratory distress syndrome (ARDS)). Sequential Organ Failure Assessment (SOFA) score on day 1 (odds ratio (OR) 1.90 (1.33-2.70); p < 0.001), oxygen flow at ICU admission (OR 1.25 (1.08-1.45); p = 0.004), and early bacterial co-infection (OR 14.94 (2.00-111.8); p = 0.009) were independently associated with the need for mechanical ventilation. Duration of mechanical ventilation was 14 (7-21) days. ICU and hospital mortality rates were 17% and 24%, respectively. All patients were treated with aciclovir and 10 received adjunctive therapy with steroids. Compared to 60 matched steroid-free controls, patients treated with steroids had a longer mechanical ventilation duration, ICU length of stay, and a similar hospital mortality, but experienced more ICU-acquired infections.

CONCLUSIONS

Severe VZV-CAP is responsible for an acute pulmonary involvement associated with a significant morbidity and mortality. Steroid therapy did not influence mortality, but increased the risk of superinfection.

The association between varicella (chickenpox) and group A streptococcus infections in historical perspective

OBJECTIVES

The aim of the research is to investigate the historical relationship between varicella and Streptococcus pyogenes infections. In the past few decades, varicella has been identified as a risk factor for invasive group A streptococcus infections. The question is whether this relationship also existed between varicella and scarlet fever in the historical era.

METHODS

The analysis begins with a search of historical medical reports on the relationship between varicella and scarlet fever epidemics in the late 19th and early 20th century, as well as in more recent empirical studies. Correlations and cross-correlations between varicella and scarlet fever are analyzed using weekly public health case reports from 1924 to 1932 for Boston, Chicago, New York City, and Philadelphia. Regression models are used to estimate the relationship between varicella and scarlet fever after controlling for seasonal forcing.

RESULTS

Historical records give limited support for a causal relationship between varicella and scarlet fever but indicate that these diseases often occurred close in time to each other. Likewise, statistical analysis shows that varicella and scarlet fever epidemics are closely aligned with each other, and varicella has a strong relationship with scarlet fever. The relationship is stronger than reported in any previous research on the two diseases.

CONCLUSION

The close correspondence of the two diseases likely depends on multiple factors, including seasonal forcing, a causal relationship, and co-infections. The results raise questions about whether this close relationship might have had a synergistic effect or a role in the evolution of S. pyogenes from the virulent, high incidence epidemics of the 19th century to the relatively benign scarlet fever of the 1950s.

The Association between Invasive Group A Streptococcal Diseases and Viral Respiratory Tract Infections

Viral infections of the upper respiratory tract are associated with a variety of invasive diseases caused by Streptococcus pyogenes, the group A streptococcus, including pneumonia, necrotizing fasciitis, toxic shock syndrome, and bacteremia. While these polymicrobial infections, or superinfections, are complex, progress has been made in understanding the molecular basis of disease. Areas of investigation have included the characterization of virus-induced changes in innate immunity, differences in bacterial adherence and internalization following viral infection, and the efficacy of vaccines in mitigating the morbidity and mortality of superinfections. Here, we briefly summarize viral-S. pyogenes superinfections with an emphasis on those affiliated with influenza viruses.

Going Out on a Limb: Do Not Delay Diagnosis of Necrotizing Fasciitis in Varicella Infection

Necrotizing fasciitis (NF) is a rare complication of varicella zoster (chicken pox) infection. Its diagnosis can be delayed or missed, which increases mortality and morbidity, because it initially presents similarly to cellulitis. We present the case of a 5-year-old boy who presented with a swollen leg, the difficulties in the diagnosis of NF, and a review of the literature. Necrotizing fasciitis complicating varicella zoster in children is associated with 3.4% mortality, although this rises to 13.6% in streptococcal toxic shock syndrome. Seventy-one percent of cases are confirmed as being caused by group A β-hemolytic Streptococcus. The association of NF with chicken pox is discussed along with the difficulties in diagnosis and treatment options. Necrotizing fasciitis is a surgical emergency and should be considered by all emergency department acute care practitioners in cases of varicella in which fever is enduring and swelling or pain is disproportionate. Because of the difficulty in diagnosis, senior opinion should be sought early.

Periorbital varicella gangrenosa: A rare complication of chicken pox

A previously healthy six year old male child presented in pediatrics ICU in state of shock with history of fever and rashes and later was diagnosed as chicken pox. He developed right sided periorbital varicella gangrenosa which is a form of necrotizing fasciitis secondary to skin infection. Patient was treated with intravenous acyclovir, antibiotics, amphotericin B, extensive debridement and later reconstruction of upper eyelid with skin grafting. Aggressive treatment helped preventing the eyeball and orbital involvement which would have necessitated orbital exenteration. However delayed presentation resulted in necrosis of orbicularis oculi and underlying tissue which resulted in graft retraction and lid dysfunction. Clinicians should be aware of this rare but fulminating condition to minimise the sight and life threatening complications associated with it.

Spinal epidural abscess from group A Streptococcus after varicella infection: a case report and review of the literature

INTRODUCTION

Spinal epidural abscess (SEA) is a very rare condition in pediatric patients. Varicella zoster infection could be a predisposing factor, and SEA should be suspected in patients with signs of secondary bacterial infection and even mild neurological signs.

CLINICAL CASE

We describe here a case of a 30-month-old girl with a history of remitting varicella infection, diagnosed for a lumbar epidural abscess and sacro-ileitis, secondary to group A Streptococcus (GAS).

DISCUSSION

This is the third case of SEA from GAS reported in the literature in a pediatric population with varicella infection. We discuss here the clinical presentation and the diagnostic challenges for SEA in childhood through a review of the literature.

Invasive infections due to Streptococcus pyogenes: seasonal variation of severity and clinical characteristics, Iceland, 1975 to 2012

Epidemiology and clinical characteristics of invasive Group A streptococcal infections (IGASI) are highly variable. Long-term studies are needed to understand the interplay between epidemiology and virulence. In a population-based study of IGASI in Iceland from 1975 to 2012, 288 cases were identified by positive cultures from normally sterile body sites. Charts were reviewed retrospectively and emm-types of viable Streptococcus pyogenes isolates (n=226) determined. Comparing the first and last decade of the study period, IGASI incidence increased from 1.09 to 3.96 cases per 100,000 inhabitants per year. The most common were emm types 1 (25%), 28 (11%) and 89 (11%); emm1 strains were most likely to cause severe infections. Infections in adults were significantly more likely to be severe during the seasonal peak from January to April (risk ratio: 2.36, 95% confidence interval: 1.34–4.15). Significant seasonal variability in severity was noted among patients with diagnosis of sepsis, respiratory infection and cellulitis, with 38% of severe infections in January to April compared with 16% in other months (p<0.01). A seasonal increase in severity of IGASI suggested that generalised seasonal increase in host susceptibility, rather than introduction of more virulent strains may play a role in the pathogenesis of these potentially fatal infections.

Diagnostic methods and management strategies of herpes simplex and herpes zoster infections

Herpes infections are extremely prevalent in the adult population. Recognizing early signs and symptoms is essential to provide effective treatment. The immunocompromised population presents treatment challenges requiring prolonged antiviral therapy and more frequent recurrences. Viral culture is often considered the gold standard diagnostic technique; however, polymerase chain reaction (PCR) should be done in tandem with culture especially for varicella zoster virus infections. Antivirals can decrease viral shedding, recurrences of herpes simplex, and hasten healing of herpes zoster. Herpes virus can be a challenging entity to treat with significant morbidity (both physically and psychologically).

Herpes zoster and radiation therapy: what radiation oncologists need to know about diagnosing, preventing, and treating herpes zoster

Herpes zoster, a viral disease that is characterized by a painful and blistering eruption in the skin, represents reactivation of latent varicella zoster (chickenpox) virus infection. In high-risk groups such as elderly or immunocompromised patients, the incidence of zoster can be as high as 50%. Radiation oncologists are likely to see zoster because cancer, and cancer therapy, can adversely affect immune function. A few reports suggest that radiation therapy is a risk factor for zoster, and that the skin eruption is often in or near the radiation treatment field. The diagnosis is typically made through clinical history and exam, but several tests are available to confirm the diagnosis and differentiate it from other infections or dermatitis. Effective management consists of prompt antiviral medication, acute pain control, appropriate precautions to limit transmission, and referral to specialists in certain cases. Despite appropriate therapy, up to 18% of patients can develop persistent postherpetic neuralgia, defined as pain more than 4 months after resolution of the rash. Several classes of pain medication are available to treat acute or long-term pain. Vaccination against zoster is recommended for patients aged 60 years or older, as it can reduce the incidence and severity of zoster.

[Life threatening secondary bacterial infection of varicella skin lesions]

As immunization coverage of varicella vaccination is low, the disease is still very frequent in Austria. Albeit the prognosis in general is good, the incidence of varicella-related hospitalization is about 6 per 100,000 in all children between 0-15 years of age, affecting mainly previously healthy children. Especially young children under the age of 5 are at risk with highest rates among children younger than one year. The most common complications are secondary bacterial infections, neurological and respiratory complications. Two cases of life threatening secondary bacterial infection are presented. One child suffered from a Toxic Shock Syndrome caused by group A streptococcus along with large necrotizing skin lesions. The second child nearly lost her left eye due to a deep orbital abscess. Both children survived without severe sequelae but had to undergo several procedures of plastic surgery. Implementation of the varicella vaccination program in the USA has shown a near elimination of deaths due to severe varicella complications. The initiation of the varicella vaccination program for children until the age of 2 in Austria should be considered to prevent complications and deaths caused by varicella.

Musculoskeletal sequelae of Varicella-zoster infection: two case reports

Varicella-zoster is a common paediatric viral infection that usually runs a benign self-limiting course but has a risk of complications. The most common sequelae are bacterial skin infections, which are usually mild. However, bacteraemia/septic shock, toxic shock syndrome, pneumonia, ataxia, encephalitis and purpura fulminans are also possible. Although rare, musculoskeletal sequelae (osteomyelitis, septic arthritis, pyomyositis and necrotizing fasciitis) can occur in otherwise healthy children. These latter complications are potentially life- and limb-threatening and must be considered in a child post-varicella with pain in a limb or joint. We describe two patients who had musculoskeletal complications after varicella: (1) a 16-month-old boy who developed pyomyositis of the thigh and septic arthritis of the hip and (2) a two-year-seven-month-old girl who developed septic arthritis of the hip and knee and a 'bare area' subperiosteal abscess of the femur. Their clinical presentations, detailed management plans and outcomes are reported. These cases highlight the importance of prompt diagnosis, appropriate investigation (including the important role of magnetic resonance imaging) and surgery when an otherwise healthy post-varicella child deteriorates.

Periorbital necrotising fasciitis following cutaneous herpes zoster

Necrotising fasciitis is a rare severe infection of the soft tissues and deep fascia, which is associated with a significant level of mortality. Involvement of the head and neck is uncommon, and necrotising fasciitis of the periorbital area even rarer. We present a case of bilateral periorbital necrotising fasciitis following shingles in an otherwise healthy immunocompetent patient.

Toxin profiling of Staphylococcus aureus strains involved in varicella superinfection

The most common complications of varicella are bacterial skin and soft tissue infections, generally due to Staphylococcus aureus and group A beta-hemolytic streptococci. The aim of this study was to characterize the toxin and antibiotic resistance profiles of S. aureus isolates involved in varicella complications. Between 2002 and 2007, the French Reference Centre for Staphylococci collected 58 S. aureus isolates involved in varicella superinfection. All the isolates were characterized by screening for 12 toxin genes, agr typing, and mecA gene detection; some isolates were also studied by spa typing, multilocus sequence typing (MLST), and resistance profiling. A major toxin gene was detected in 53% (31/58) of the isolates (genes for exfoliative toxins A and B, 17.2%; Panton-Valentine leukocidin gene, 8.6%; toxic shock syndrome toxin 1 gene, 27.6%). Most clinical manifestations were directly compatible with the classical activity of these toxins. Nineteen isolates (33%) were resistant to methicillin, and 12 of these isolates belonged to an emerging agr-2, ST5 clone that harbors the toxic shock syndrome toxin 1 gene. These data should be considered in the management and treatment of patients with varicella complicated by S. aureus superinfection. Antibiotics that decrease toxin production, such as clindamycin, may provide benefit, and their efficacy against bacterial superinfections in children with varicella should be studied.

Survey of childhood empyema in Asia: implications for detecting the unmeasured burden of culture-negative bacterial disease

Background

Parapneumonic empyema continues to be a disease of significant morbidity and mortality among children despite recent advances in medical management. To date, only a limited number of studies have assessed the burden of empyema in Asia.

Methods

We surveyed medical records of four representative large pediatric hospitals in China, Korea, Taiwan and Vietnam using ICD-10 diagnostic codes to identify children <16 years of age hospitalized with empyema or pleural effusion from 1995 to 2005. We also accessed microbiology records of cultured empyema and pleural effusion specimens to describe the trends in the epidemiology and microbiology of empyema.

Results

During the study period, we identified 1,379 children diagnosed with empyema or pleural effusion (China, n = 461; Korea, n = 134; Taiwan, n = 119; Vietnam, n = 665). Diagnoses of pleural effusion (n = 1,074) were 3.5 times more common than of empyema (n = 305), although the relative proportions of empyema and pleural effusion noted in hospital records varied widely between the four sites, most likely because of marked differences in coding practices. Although pleural effusions were reported more often than empyema, children with empyema were more likely to have a cultured pathogen. In addition, we found that median age and gender distribution of children with these conditions were similar across the four countries. Among 1,379 empyema and pleural effusion specimens, 401 (29%) were culture positive. Staphylococcus aureus (n = 126) was the most common organism isolated, followed by Streptococcus pneumoniae (n = 83), Pseudomonas aeruginosa (n = 37) and Klebsiella (n = 35) and Acinetobacter species (n = 34).

Conclusion

The age and gender distribution of empyema and pleural effusion in children in these countries are similar to the US and Western Europe. S. pneumoniae was the second leading bacterial cause of empyema and pleural effusion among Asian children. The high proportion of culture-negative specimens among patients with pleural effusion or empyema suggests that culture may not be a sufficiently sensitive diagnostic method to determine etiology in the majority of cases. Future prospective studies in different countries would benefit from standardized case definitions and coding practices for empyema. In addition, more sensitive diagnostic methods would improve detection of pathogens and could result in better prevention, treatment and outcomes of this severe disease.

[Postvaricella cerebellar ataxia in children in Costa Rica]

INTRODUCTION

Postvaricella cerebellar ataxia (PVCA) and meningoencephalitis are the most common acute neurological complications of chickenpox. The objective of this study was to describe the clinical presentation, management, and outcome of children hospitalized with PVCA in the only pediatric hospital of this developing country, where routine varicella immunization is not yet available.

METHODS

We performed a retrospective chart review of children aged 1-12 years old admitted to the National Children's Hospital of Costa Rica from January 1997 to June 2004 with a diagnosis of PVCA.

RESULTS

Among the 441 immunocompetent patients admitted for varicella zoster virus-associated complications during this period, 37 (8.4%) had PVCA. Twenty-four of the 37 (64.9%) patients were boys. The mean (range) age was 5 (1-10) years. The median (range) interval from rash onset to admission was 2 (1-3) days. Cerebrospinal fluid analysis was available in 22 (59.5%) patients and was normal in all. Head computed tomography showed cerebral edema in six out of 18 patients (33.3%). Intravenous acyclovir was administered to 23 patients but no significant differences in clinical manifestations or outcomes were observed in treated versus untreated patients. The mean (range) length of ataxia was 4 (1-10) days, and seven (19%) patients were still ataxic on discharge. The mean (range) length of hospital stay was 4.4 (2-11) days. Minor sequelae were documented in 13 out of 24 (54.2%) patients during follow-up visits and telephone contacts.

CONCLUSIONS

PVCA is usually associated with a favorable prognosis; however, neurological sequelae can occur. The real utility of acyclovir treatment and brain imaging studies in these children remains controversial.

Varicella with stridor: think group A streptococcal epiglottitis

Bacterial superinfection complicating varicella is not uncommon, but airway complications are rare. We report a case of varicella in a 2-year-old boy complicated by life-threatening stridor secondary to group A streptococcal epiglottitis.

Severe complications of chickenpox in hospitalised children in the UK and Ireland

AIMS

To estimate the annual incidence of hospitalisations due to severe complications of varicella, describe the complications and estimate annual mortality.

METHODS

Active surveillance throughout the UK and Ireland for 13 months by paediatricians notifying cases to the British Paediatric Surveillance Unit and completing a questionnaire. The case definition was any child aged <16 years hospitalised with complicated varicella, as defined by a list of conditions, or admitted to ICU/HDU with varicella.

RESULTS

188 cases were notified for the surveillance period, of which 112 (0.82/100 000 children/year) met the case definition and were not duplicates. Confirmed cases had a median age of 3 years (range 0-14). The complications were: bacteraemia/septic shock (n = 30), pneumonia (n = 30), encephalitis (n = 26), ataxia (n = 25), toxic shock syndrome/toxin-mediated disease (n = 14), necrotising fasciitis (n = 7), purpura fulminans/disseminated coagulopathy (n = 5), fulminant varicella (n = 5) and neonatal varicella (n = 3). 52 children (46%) had additional bacterial infections. Six deaths were due, or possibly due, to varicella, including one intrauterine death. Four of the other five children who died (ages 2-14 years) had a pre-existing medical condition. Sequelae on discharge were reported for 41 cases (40%), most frequently ataxia or skin scarring. The median length of hospital stay was 7 days (range 1-68).

CONCLUSIONS

This study provides a minimum estimate of severe complications and death resulting from varicella in children in the UK and Ireland. Most complications, excluding deaths, occur in otherwise healthy children and thus would be preventable only through a universal childhood immunisation programme.

Varicella vaccination in children with atopic eczema

Chickenpox in children may be complicated by local or systemic bacterial infections. Group A streptococci and S. aureus are the predominant pathogens. Children with atopic dermatitis are particularly prone to bacterial superinfection. After the introduction of universal varicella vaccination in the USA ten years ago, the number of serious bacterial soft tissue infections in children dropped significantly. Since 2004, the VZV immunization has also been included in the routine German series.Many children with atopic dermatitis have not been immunized because of concerns on the part of parents or physicians. Recent studies demonstrated the safety and efficacy of VZV vaccination in children with atopic dermatitis who appear to benefit particularly from this vaccination.

Role of bacterial superinfections in the pathogenesis of postzosteric neuralgia

Varicella-zoster virus (VZV) is an alpha-herpes virus that causes varicella (chickenpox), establishes latency in dorsal root ganglia and may reactivate to cause herpes zoster (shingles). Postherpetic neuralgia is the most common debilitating complication of herpes zoster. It is currently supposed that scarring of the dorsal root ganglia and atrophy of the dorsal horn as a result of intense inflammation may play a central role in the pathogenesis of this condition. The exact pathogenesis of the inflammatory reaction leading to persistent ganglion damage is still poorly understood. However, immune suppression is a recognized risk factor for the development of postzosteric neuralgia in zoster patients (increased risk, e.g., in aged patients over 80 years or diabetes mellitus patients). There is some evidence that remote streptococcal and staphylococcal infections may induce immunologic disease mechanisms consequently affecting the central nervous system. Since streptococcal and/or staphylococcal superinfection of skin lesions is common in herpes zoster, we present a hypothesis of immunopathogenesis of postzosteric neuralgia, i.e., as the result of augmentation of local ganglion inflammation due to bacteria-driven clonal expansion of VZV-specific T-cell subsets in the affected skin. Based on the aforementioned hypothesis it is interesting: (1) to study the impact of concomitant systemic antibiotic treatment to the standard antiviral regimen on the rate and severity of both bacterial superinfection of zoster skin lesions and postzosteric neuralgia and (2) to quantify the VZV-specific T-cell response as a function of the degree of bacterial superinfection of zoster skin lesions. Challenging of the present hypothesis should provide an effective means of preventing postherpetic neuralgia by preventing and consequently treating the bacterial superinfection of zoster skin lesions.

Chicken pox after pediatric liver transplantation

Previous case series have reported serious complications of chicken pox (CP) after pediatric liver transplantation (PLT), mainly due to visceral dissemination. The goal of our study was to determine the incidence, risk factors, and outcomes of CP after PLT. A case-control study of all CP infections in pediatric transplant recipients followed at our center from September 1993 to April 2004 was performed. Data were collected before and after infection and at the same time points in age-, gender-, and transplant year-matched controls. Potential risk factors prior to CP and adverse outcomes after infection were compared between cases and controls. Twenty (6.2%) developed CP at a median of 1.8 yr (0.6-4.8) after PLT. All CP infections were cutaneous, with no evidence of organ involvement. Twelve were hospitalized: 9 only to receive intravenous acyclovir and 3 stayed > or =2 weeks for other complications. Risk factors were not statistically different among cases and controls. Of the outcomes analyzed, cases were significantly more likely to develop non-CP infections within one year of CP than controls (Hazard Ratio = 12.6, 95% confidence interval = 3.1-51.7; P < 0.001). These infections were often bacterial and occurred long after CP infection. In conclusion, CP is uncommon after PLT and has a low likelihood of organ dissemination. No risk factors were identified. Some cases required prolonged hospitalizations. Close monitoring for the development of late bacterial infections is warranted.

Acute osteomyelitis as a complication of varicella

Varicella is a common viral infection in childhood, and acute osteomyelitis is one of the rare but serious complications. We report two cases of osteomyelitis as a complication of varicella. The possibilities and limitations of the different imaging modalities are discussed, as well as imaging findings during the course of this condition.

Human herpes viruses in pregnancy: cytomegalovirus, Epstein-Barr virus, and varicella zoster virus

Viruses of the human herpesvirus family can have profound effects on pregnancy. Primary maternal infection with cytomegalovirus (CMV) and varicella during pregnancy has been associated with fetal abnormalities and neonatal disease. Public awareness of the role of cytomegalovirus in the etiology of developmental disorders and chronic disabilities needs to increase. With time, we may see new interventions for treatment of infected pregnant women and prevention of long-term effects. Attention must be focused on development of a safe and effective vaccine. With the introduction of an efficacious varicella vaccine, the rate of varicella in pregnancy is expected to decrease dramatically. Physicians caring for women have the opportunity to prevent the complications of varicella by identifying and vaccinating susceptible women.

Hospitalizaciones por varicela en el Hospital Infantil La Fe (Valencia 2001-2004)

INTRODUCTION

Varicella is a common, highly contagious disease. It is usually benign but has potentially serious complications.

PATIENTS AND METHODS

To assess the clinical characteristics and the associated cost of varicella hospitalization, we reviewed the medical records of children hospitalized for varicella between 2001 and 2004. Children with coincidental varicella hospitalized for a different reason were excluded.

RESULTS

Of 1177 children with varicella attended at the emergency room, 101 (8.6 %) were hospitalized. The median age was 3.2 years (21 days to 18.9 years). Twenty-eight children had underlying disease. Thirty-seven children had no complications and the reason for admission was: a) risk of severe varicella (21 immunocompromised children, three neonates), and b) high fever or observation (13 cases). The 64 remaining children were admitted for 66 complications of varicella. The most common complications were skin/soft tissue infections (33 patients) and the leading cause was Streptococcus pyogenes (n = 13) and Staphylococcus aureus (n = 10) isolated in blood or the site of infection. Other complications were pneumonia (13 children), neurological (febrile seizures in nine, meningoencephalitis in two, acute disseminated encephalomyelitis in one, cerebellitis in one), hematological (neutropenia in one, Henoch-Schönlein purpura in one and thrombopenic purpura in three) and osteoarticular (synovitis in one and septic arthritis in one). One patient died of multiorgan failure. During the study period, the rate of emergency room visits due to varicella doubled and the number of admissions for complications tripled. The mean length of hospital stay was 6.8 days (range: 1-28 days) and the total associated cost was 397,314.14 Euro, excluding symptomatic treatment.

CONCLUSIONS

The high morbidity associated with varicella and its complications, as well as the high social costs of this disease, support the implementation of routine varicella vaccination. This could reduce the total number of cases, their severity, direct costs, generated by medical care, and indirect costs, generated by the disease and hospitalization.

Complications of varicella in healthy children in Izmir, Turkey

BACKGROUND

The purpose of the paper was to evaluate the indications of hospital admissions and complications of varicella infection in immunologically healthy children.

METHODS

Between 1997 and 2001, patient records of children hospitalized due to varicella infection were reviewed. Incidence and clinical spectrum of complications and their distribution related to age and seasonal variations were analyzed.

RESULTS

A total of 178 immunocompetent children were hospitalized for varicella complications during the study period. This resulted in a crude incidence of 6.3/100 000 population at risk. All hospital admissions were due to accompanying complications. The majority of complications occurred in preschool-age children with a median age of 3 years. No gender predominance was found. The most frequent complications were infectious complications, which were observed in 79 children (44%). Superinfections of the skin were present in 24 patients. Pneumonia was observed in 59 children: 49 had bacterial, 10 had viral pneumonia. Pyogenic arthritis was seen in two children and one had concomitant osteomyelitis. Group A beta-hemolytic streptococci were recovered from two patients with invasive bacterial infections. A total of 68 (38%) neurologic complications were observed. Cerebellar ataxia was present in 24, encephalitis was present in 17. Infectious complications occurred more frequently in younger children (median age: 2 years), whereas neurologic complications occurred at an older age (median age: 6 years). Hematologic complications were seen in nine children. There was a seasonal distribution of complications with a peak in January.

CONCLUSION

Complications of varicella requiring hospitalization in immunocompetent children are more frequent than previously thought.

Therapy of other viral infections: herpes to hepatitis

Over the past several years, there has been an increase in knowledge pertaining to the diagnosis and management strategies for the herpes family (Types 1-8), the pox viruses, mumps, measles, rubella, and parvovirus B19 as well as the viral etiologies of hepatitis. Various antiviral treatments, such as nucleoside analogs and interferon therapy, have been available to reduce the signs and symptoms of these common viral infections. This article summarizes the preferred treatment strategies to be employed for each of the viruses for reducing severity, duration, recurrences (notably in the herpes family), transmission rates, as well as preventive alternatives. The majority of the therapeutic options attenuate the course of disease. Treatment decisions are driven by knowledge of the natural history and often are tailored to incorporate clinical circumstances for individual patients. Promotion of community awareness and the development of vaccines should be emphasized in the battle against these common viruses, particularly the herpes simplex viruses, the pox viruses, and hepatitis B.