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Background The Indian Armed Forces, on entry, vaccinates all cadets and recruits with varicella vaccine for the prevention of varicella. This health technology assessment (HTA) report puts forth evidence for HTA of varicella vaccination in the Armed Forces in various domains namely clinical, societal, ethical, economic, and legal. Methods The policy question under each domain has been developed according to best-practice methods for HTA. The costs included were hospitalization cost due to varicella infection; training lost cost; the varicella vaccine cost; cost of the side effects of vaccine; and the outbreak investigation cost. The incremental cost-effectiveness ratio (ICER) for varicella cases averted and man-days saved, and quality-adjusted life years (QALYs) gained due to varicella vaccination strategy were calculated. Results Evidence suggests a reduction of 81% in hospitalization rates with 19392 man-days saved per 1 lakh population due to varicella vaccination strategy. The ICER for varicella cases averted is estimated to be Rs 56732/- per case averted and Rs 5687/- per man-day saved. QALYs gained due to two-dose varicella vaccination strategy is estimated to be 1152 per 1 lakh population with cost per QALY gained Rs 95735/-. Conclusion The study showed a large reduction in hospitalizations and consequently man-days lost after the introduction of the vaccination strategy. The QALYs was another aspect of importance brought out by this study. Thus, a two-dose vaccination strategy for varicella-zoster virus (VZV) for the Armed Forces trainees is a cost-effective policy.

What to do in the event of a varicella infection in pregnant women or children is sometimes not well known. Several therapies are available to doctors; specific immunoglobulins, anti virals, vaccination. We propose a decision tree

Background: This is a retrospective study undertaken to analyse the maternal and fetal outcome of varicella infection during pregnancy. Methods: This is a retrospective observational study done in Kerala Institute of Medical Sciences, Trivandrum, a tertiary care hospital in South India. Sixty nine women infected with chickenpox during pregnancy from January 2009 to February 2018 (9 years) were taken for the study. Results: The incidence of chickenpox during pregnancy in our study was 33.7 in 10000 pregnancies. There were no spontaneous miscarriages. The incidence of congenital anomalies was 7.2% and when compared to the overall obstetric population of the nine year study period in which the incidence was 6.5 %, there was no statistical significance (p- 0.99). The incidence of preterm labour was 4.7% and when compared to the overall obstetric population in which the incidence was 15 %, there was a statistically significant less incidence (p- 0.035). The incidence of polyhydramnios was 4.7% and when compared to the overall obstetric population in which the incidence was 1%, there was a statistically significant increased incidence (p - 0.018). The incidence of fetal growth restriction was 13% and when compared to the overall obstetric population in which the incidence was 12.4%, there was no statistically significant difference (p- 0.963) Conclusions: The maternal and fetal complications with chickenpox infection during pregnancy were more when infected in the first trimester. Early treatment, screening and followup will reduce the maternal and fetal morbidity

What to do in the event of a varicella infection in pregnant women or children is sometimes not well known. Several therapies are available to doctors; specific immunoglobulins, anti virals, vaccination. We propose a decision tree

What to do in the event of a varicella infection in pregnant women or children is sometimes not well known. Several therapies are available to doctors; specific immunoglobulins, anti virals, vaccination. We propose a decision tree

IgA vasculitis (IgAV), formerly named as Henoch Schönlein Purpura, is an IgA-mediated systemic small vessel vasculitis with skin, gastrointestinal tract, joints, and kidneys involvement. It is the most common vasculitis in childhood. Varicella-zoster virus-associated IgA vasculitis has been reported previously in few cases. However, IgA vasculitis complicated by chickenpox rarely occurred severe hemorrhagic manifestation and had not yet been reported. Herein, we present a case of an eight-year-old girl who developed IgA vasculitis complicated by disseminated intravascular coagulation and multiple organ dysfunction syndrome, including severe acute pancreatitis and acute liver failure secondary to varicella-zoster virus infection and finally underwent blood purification including hemoperfusion, plasmapheresis, and continuous renal replacement therapy. Tumors and other diseases affecting coagulation and platelet function, such as systemic lupus erythematosus, ANCA-associated vasculitis, primary thrombocytopenia, and secondary thrombotic microangiopathies, have been excluded during her hospitalization. Varicella was considered to be the cause of the severe complications. A possible mechanism for the occurrence of severe complications is that chickenpox infection induces the production of heparin-like substances disturbing normal coagulation function, and finally occurs uncontrolled hemorrhage manifestation including gastrointestinal hemorrhage, uncontrolled bleeding at the catheter placement and injection site. She eventually was discharged after undergoing 37 days of treatment by antibiotics, antiviral drugs, protamine neutralizing heparin therapy and various blood products transfusion including platelets, red cells, fresh frozen plasma, cryoprecipitate, fibrinogen, and prothrombin complex transfusions. At the end of a month follow-up, the patient showed the purpuric rashes had nearly faded and had no sign of complication including the gastrointestinal tract, liver, and pancreas. Renal function tests and routine analysis of blood were normal. Hematuria(3+~4+) and proteinuria(1+~2+) can be seen in her urinalyses. At the 5th month follow-up, her renal function test and her urinalysis were normal, and her oral steroids were stopped completely. On this occasion, we should reduce the dose of heparin or no heparin in blood purification for IgA vasculitis complicated by chickenpox to reduce the incidence of severe bleeding or death.

Varicella infection commonly called chicken pox is a benign self-limiting infection in children. Neurological complications following varicella infection are rare. Cerebral venous sinus thrombosis following varicella infection is very rare. Herewith we report a child who developed transverse and sigmoid sinus thrombosis following chicken pox.

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.

Medulloblastoma is the most common malignant pediatric brain tumor. Survival rates range between 50% and 80% depending on histology and other biologic features, metastases, and treatment approach. Prader-Willi syndrome (PWS) is a genetically inherited disorder characterized by dysmorphic features, mental retardation, obesity, and hypogonadism among other features. We describe a 10.5-year-old girl with PWS and previous standard-risk medulloblastoma that relapsed in the pons 3 years after the end of treatment. Diagnosis of relapse was delayed by a preceding varicella infection, an initial clinical/radiologic response to steroids and the unusual location, and was confirmed with a stereotactic biopsy. Second-line therapy was commenced, however, the patient rapidly deteriorated and died. This is the first report of medulloblastoma in a patient with PWS.

Herpes zoster (shingles) is the reactivation of dormant varicella zoster virus in individuals who previously experienced varicella infection or vaccination. Herpes zoster can occur in pregnancy, although it is rare. This case report describes the clinical presentation and diagnosis of herpes zoster and reviews current recommendations for treatment. Preventative measures and the role of immunization are discussed in addition to clinical implications for intrapartum, postpartum, and newborn care to guide practitioners in caring for women experiencing or exposed to herpes zoster in pregnancy.

Live viral vaccines have historically been avoided in children after solid organ transplantation. Multiple reports of safety and immunogenicity, largely in the pediatric liver transplant population, have led to a reconsideration of this recommendation. Here, we report the case of a 4-year-old boy who inadvertently received the live attenuated MMR-varicella vaccine (MMRV) at a routine well-child visit 16 months after receiving a living donor kidney transplant. This was not known until after he was admitted with rash and documented disseminated varicella infection 5 weeks later. He was treated with intravenous acyclovir followed by oral therapy and recovered fully. This case and its discussion illustrate what is still unknown about the risk-to-benefit ratio of live viral vaccination in any individual transplant recipient. Criteria to determine which patients should receive these vaccines should be evaluated before their use after transplant becomes routine, and all recipients and their families should be counseled to have a low threshold to seek medical care for any febrile illness or rash after live viral vaccination.

Herein we report a case of acute liver failure (ALF) and hemophagocytic lymphohistiocytosis (HLH) induced by varicella infection, successfully rescued by a combination therapy of acyclovir, supportive care, and immunosuppression with dexamethasone and etoposide. A previously healthy 16-year-old boy presented with generalized rash, fever, severe abdominal pain, and abnormal liver function within 4 d. Chickenpox was suspected, and acyclovir and intravenous immunoglobulin were started on admission. However, the patient’s condition deteriorated overnight with soaring transaminases, severe coagulopathy and encephalopathy. On the fourth day of admission, pancytopenia emerged, accompanied by hypofibrinogenemia and hyperferritinemia. The patient was diagnosed with ALF. He also met the diagnostic criteria of HLH according to the HLH-2004 guideline. Polymerase chain reaction (PCR) amplifications of varicella-zoster virus (VZV) were positive, confirming that VZV was a causative trigger for ALF and HLH. In view of the devastating immune activation in HLH, immunosuppression therapy with dexamethasone and etoposide was administered, in addition to high dose acyclovir. The patient’s symptoms improved dramatically and he finally made a full recovery. To our knowledge, this is only the second report of a successful rescue of ALF associated with HLH, without resorting to liver transplantation. The first case was reported in a neonate infected by herpes simplex virus-1. However, survival data in older children and adults are lacking, most of whom died or underwent liver transplantation. Our report emphasizes the clinical vigilance for the possible presence of HLH, and the necessity of extensive investigation for underlying etiologies in patients presenting with indeterminate ALF. Early initiation of specific therapy targeting the underlying etiology, and watchful immunosuppression such as dexamethasone and etoposide, together with supportive therapy, are of crucial importance in this life-threatening disorder.

Immunocompromised patients exposed to varicella may experience significant morbidity and a 7% mortality rate. Management and outcome of an outbreak of varicella infection among hospitalized pediatric hemato-oncology patients using the guidelines of the American Academy of Pediatrics Committee on Infectious Diseases are presented.This retrospective study describes an outbreak of varicella infection between February 2011 and June 2011. Data were retrieved from the patients' files. Positive polymerase chain reaction results for varicella zoster virus from vesicular skin lesions were used for the diagnosis of varicella infection.Twelve pediatric hemato-oncology patients experienced 13 episodes of varicella infection, 11 underwent 1 episode each and 1 patient had 2 episodes. All exposed patients without immunity received varicella zoster immune globulins or intravenous immunoglobulin and were isolated as recommended by the guidelines. Infected patients received intravenous acyclovir. One patient with acute lymphoblastic leukemia at induction chemotherapy died. All the other patients survived.Our experience in the management of hospitalized immunocompromised patients exposed to varicella was that a positive IgG serology did not confer protection after exposure to varicella infection and thus can not serve as a marker for immunity. Unlike the isolation period sufficient for immunocompetent patients, crusted lesions can be contagious and thus require extended isolation for immunocompromised patients. Patients receiving rituximab are at greater risk of having persistent or recurrent disease. Studies with a larger sample size should be performed to better assess the management of immunocompromized patients exposed to varicella.

Background: Varicella is a common and usually mild disease but it has great importance in regard to general infectious morbidity. The current study aimed to characterize possible risk factors of varicella epidemiology in Bulgaria, a country where infection follows its natural epidemiological pattern as no mandatory or recommended vaccine is currently applied. Methods: Administrative regions of Bulgaria were used as units of observation and a set of sociodemographic and economic determinants, as well as geographic location (south or north) were tested for associations with the mean 3-year varicella incidence rates (2013–2015). Results: The proportion of urban population, proportion of females, number of health care units and proportion of urban population aged

What to do in the event of a varicella infection in pregnant women or children is sometimes not well known. Several therapies are available to doctors; specific immunoglobulins, anti virals, vaccination. We propose a decision tree

Varicella is a common and highly contagious disease of childhood which is caused by varicella zoster virus (VZV). A 83 year old man consulted our clinic with black crusted lesions without ichting on his trunk for one week. Dermatological examination showed multipl necrotic ulcerations on his trunk, scalp and upper parts of extremities and a few vesicles on his left femoral area. He has hypertension for 45 years, diabetes mellitus for 10 years, chronic kidney failure for one year and because of those diseases he’s been using a lot of medicines. He had a heart attack and coronary bypass surgery six months ago. He had many infections in different times and had given many antibiyotics. The patient consulted Dermatolgy for skin lesions. Skin biopsy showed VZV infection. We reported this case due to its rarity in older ages and to emphasize that the possibilty of primary varicella infection should be kept in mind as an entity for differential diagnosis during the clinical evolutions vesiculobullous diseases in older ages.

Varicella is a common, highly contagious viral infection of childhood. Varicella is a usually benign and self-limited disease, but it can be complicated by severe bacterial infections, especially in immunocompromised hosts. In this study, we describe a previously healthy 3-months-old infant who was admitted with high fever, cough, and respiratory distress, who had a history of varicella infection three weeks before, with exposure from her adolescent, unvaccinated sister. A lung abscess caused by Staphylococcus aureus complicating the varicella infection was discovered. The patient was aggressively treated with drainage of the abscess and intravenous antibiotics and had a good recovery. Keywords: Varicella, Lung abscess, Infant

What to do in the event of a varicella infection in pregnant women or children is sometimes not well known. Several therapies are available to doctors; specific immunoglobulins, anti virals, vaccination. We propose a decision tree

A 46-year-old man presented with breathlessness, icterus, passage of dark-coloured stools and urine for 1 day. His medical history included recent treatment for varicella infection with oral acyclovir and using Siddha medicines for constipation occasionally. On evaluation, he had bilateral

Natural circulating antibodies (NAbs) to endogenous regulators have shown to be potential biomarkers in medicine. Due to the lack of reliable assays, only few of them have been well studied. To employ NAbs as biomarkers, an evaluation of changes over the course of a treatment is required. This paper describes our work to analyze the dynamics of NAbs titer to interferon-gamma (IFN-γ) among healthy children of different age and in patients with varicella infection receiving an antiviral drug Anaferon for children (AC, the API are highly diluted antibodies to IFN-γ) in comparison with placebo, and to correlate the findings with the treatment results. IFN-γ plays an essential role during varicella infection, and this fact causes the consequent increase of NAbs to IFN-γ level. The mean anti-IFN-γ NAbs level in the healthy volunteer group was 101 × 103 U/ml (age: 0-15 years), which was significantly lower than the mean pre-treatment value in patients with varicella infection 167 × 103 U/ml (age: 3-17 years). In the AC group, the NAbs level observed on days 5 and 10 decreased significantly to a level of 154 × 103 U/ml, whereas in the placebo group it continued to rise in a time-dependent manner reaching 229 × 103 U/ml on day 10. Our findings suggest that treatment with AC is characterized by "normalization" of the anti-IFN-γ NAbs levels in patients with varicella infection.

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.

Highlights • Recurrent herpes zoster (HZ) is a rare condition and usually occurs unilaterally. • HZ involving bilaterally, so called herpes zoster bilateralis, is extremely rare. • Possible hypothesis is the virus spread across a spinal cord to contralateral nerve. • Risk factors of this condition are Asian race, female and immunocompromised status., A single varicella infection usually causes lifelong immunity, so recurrent varicella infection is considered rare. Reactivation of the virus as herpes zoster usually develops after a latent period. Here, we report a case of a 48-year-old immunosuppressed patient who presented with rapid-onset symmetrical bilateral papulovesicular eruptions on both legs 3 weeks after having recurrent varicella infection that had been treated with intravenous acyclovir. Varicella zoster virus (VZV) Ag testing was performed on vesicular lesions. The positive result confirmed that VZV had reactivated. It presented in the form of herpes zoster duplex bilateralis symmetricus. This condition is rare and occurs primarily in immunocompromised female hosts.

We report the clinical course and outcome of primary varicella infection in six children with systemic juvenile idiopathic arthritis (sJIA) receiving tocilizumab. None had disseminated or fatal varicella infection, but one patient developed macrophage activation syndrome (MAS) and another had an arthritis relapse. All patients had a significant elevation of serum IL-6 levels, and the two children who developed MAS or arthritis relapse showed high serum IL-18 levels, which could cause a sJIA flare-up.

A 12 year girl presented with left eye (LE) loss of vision for four days. Fundus examination and fluorescence angiography revealed LE central retinal artery occlusion (CRAO). She had multiple rashes all over the body. IgM-Varicella antibody assay corresponded with varicella infection and she was diagnosed with CRAO associated with varicella dermatitis.J Nepal Paediatr Soc 2016;36(1):78-81.

AIM The varicella-zoster virus causes infections that are often mild but can cause substantial morbidity and mortality in otherwise healthy children. We examined trends in varicella-related hospitalisations before and after the implementation of a national two-dose varicella vaccination programme in Israel in September 2008. METHODS This retrospective chart review, performed at three tertiary care paediatric hospitals in greater Tel Aviv, compared data from 2004 to 2008 and 2009 to 2012, before and after the varicella programme was launched. It included all children to the age of 18 who were hospitalised for conditions associated with the varicella infection. RESULTS After the vaccination programme was introduced, the number of children hospitalised for varicella fell by 63% (p < 0.5), from 38.9 to 14.5 per 10 000, and there was a 75% reduction in children aged one to six. During the same period, the percentage of hospitalised children who were immunocompromised rose from 9.7% to 18.4% (p < 0.05). The most common complications were soft-tissue infections (60%), and the most prevalent pathogens were Group A β-haemolytic streptococcus (53%) and Staphylococcus aureus (32%). CONCLUSION The introduction of a two-dose immunisation programme dramatically decreased the varicella burden in Israel, leading to a major reduction in hospitalisation admissions linked to the infection.

Ozet Eritema nodosum genellikle tibia on yuzunde yerlesen kirmizi-mor renkte nodullerle gorulen subkutan dokunun inflamatuvar bir lezyonudur. Cocuklarda siklikla streptokokkal enfeksiyonlar ve primer tuberkuloz ile birlikte gorulur. Eritema nodosum tanisi esasen klinik olarak konan bir hipersensitivite reaksiyonudur. Sucicegi cocukluk caginin sik gorulen bir enfeksiyon hastaligidir. Biz gecirilmis varisella enfeksiyonu sonrasi eritema nodosum gelisen okul cocugu olguyu sunmak istiyoruz. 6 yas 7 aylik kiz hasta on gundur devam eden her iki bacakta kirmizi renkte sislikler yakinmasi ile basvurdu. Onbes gun once doktor tanili sucicegi gecirme oykusu vardi. Fizik muayenesinde her iki bacak on yuzunde kirmizi-morumsu, deriden kabarik, agrili, yaklasik 1-2 cm capli nodulleri mevcuttu. Varisella zoster IgM ve IgG’si pozitif bulundu. Hastada mevcut oyku ve varisella serolojisi ile varisella enfeksiyonu sonrasi EN gelistigi dusunuldu. (J Pediatr Inf 2015; 9: 000-000) Anahtar kelimeler: Cocuk, eritema nodosum, sucicegi Abstract Erythema nodosum which is seen red-purple noduls on the anterior surfaces of tibia is an inflammatory lesion of subcutaneous tissue. It is encountered with streptoccoccal infections and primary tuberculosis in children. Erythema nodosum clinically diagnosed is a hypersensitivity reaction. Varicella is an infectious disease which is commonly seen in childhood. We want to present a school-aged child case who developed erythema nodosum following varicella infection. A 6.5 year old girl was admitted with the complaints of red color swellings on both legs for 10 days. Fifteen days ago she was diagnosed as varicella by the physician. On the physical examination, red-purple, raised from skin, painfull, 1-2 cm in diameter noduls were found on the anterior surface of legs. Varicella zoster IgM and IgG were detected positive. According to the her past history and varicella serology erythema nodosum secondary to varicella infection was considered. (J Pediatr Inf 2015; 9: 000-000)

Varicella zoster virus (VZV) can present with multiple neurological complications both during and in the immediate post-infectious period. Among these, idiopathic intracranial hypertension (IIH) is a rare but treatable entity exclusively reported in children and adolescents. This report describes a 23 year old female who developed headache and visual disturbances on the third week after the exanthema, who satisfied the diagnostic criteria for IIH. Clinical improvement was achieved with medical management. To the best of our knowledge, this is the first report of IIH in an adult patient following 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.

Necrotising fasciitis (NF) is an infrequent yet significant complication of primary varicella infection in immunocompetent children. We report a case of a 4-year-old girl who presented three days into her chicken pox illness, with a rapidly progressing, severely tender erythematous rash surrounding one chicken pox lesion on her thigh. She required intravenous antibiotics, two surgical debridements, a skin graft and a prolonged stay in the paediatric intensive care unit, but ultimately we were able to save her life and limb. NF is a rare complication of chicken pox that has high morbidity and mortality that requires prompt and specific treatment.

Venous Thromboembolism (VTE) post varicella infection is a rare complication owing to vascular endothelial damage, accelerated atherosclerosis and antibody-mediated hypercoagulable state. Pulmonary Embolism (PE) is a life threatening condition presented with sudden onset dyspnoea and refractory hypoxemia. We report a case of post varicella extensive thrombotic complication which involved deep veins of lower limbs and pulmonary vasculature.

Introduction/Objectives: Neurological complications caused by varicella are estimated to occur in approximately 0.01-0.03% of infections. Frequent complications are cerebellar ataxia and encephalitis while the rare complications are facial paralysis, transverse myelitis, aseptic meningitis, Guillain-Barre syndrome, ventriculitis, optic neuritis, peripheral motor neuropathy, cerebral angiitis and Reye´s syndrome. Facial palsy can be a result of preeruptive hematogenous or neurogenous spread of varicella zoster virus. Objectives: Review the case of acute peripheral facial palsy as a rare complication of varicella. Case report: A 3-year-old girl presented with a 5-day history of fever and widespread vesicular/pustular rash typical for varicella with clinical signs of secondary bacterial infection of skin, and we clinically confirmed diagnosis of impetigo as a varicella complications. The fifth day after the rash appears she developed inability to close left eye and facial asymmetry with the lower left corner of the lips. There was no clinical history of retroauricular pain, hyperacusis, decreased production of tears and altered taste. Complete neurological examination revealed left peripheral facial nerve palsy without any abnormal features. The diagnosis facial nerve palsy associated with varicella was based on clinical, laboratory and neurophysiological findings. Aside from local therapy and antibiotic clindamicin for 7 days, patient was treated with acyclovir 10mg/kg IV q8h for 7 days and oral prednisolone (1 mg/kg q24h ) in tapering doses for 2 weeks. In the third week follow-up complete recovery of neurological deficit was noted. Hematological– biochemical tests registered a mild increase inflammatory markers and neutrophilia, until liver and kidney enzyme analysis were within reference range. Lumbar puncture obtained first day of admission and CSF analysis showed mononuclear pleocytosis (108 white cell/mm3 , 86, 4 % lymphocytes), glucose and protein level was in normal range. CSF cultures for bacteria, fungus and tuberculosis were negative. Serological test for B. burgdorferi was nonreactive. The patient had a bilateral type A tympanogram, stapedial reflex was absent in the left ear. Ocular fundus (FOU) was normal. Conclusions: We suggest that, aside from a frequent central nervous complications, children with varicella should be monitored closely for facial nerve palsy as well. The prognosis of facial palsy due to varicella is generally good and 80% cases recover with or without treatment, but specific acyclovir and prednisolone therapy may accelerate the complete recovery like in our case. Keywords: facial nerve palsy, varicella.