Chickenpox

Overview of Chickenpox

Chickenpox is a highly contagious disease caused by the varicella-zoster virus (VZV). It can cause an itchy, blister-like rash. The rash first appears on the chest, back, and face, and then spreads over the entire body, causing between 250 and 500 itchy blisters.

Chickenpox can be serious, especially in babies, adolescents, adults, pregnant women, and people with bodies that have a lowered ability to fight germs and sickness. The best way to prevent chickenpox is to get the chickenpox vaccine.

Chickenpox used to be very common in the United States. In the early 1990s, an average of 4 million people got chickenpox, 10,500 to 13,000 were hospitalized, and 100 to 150 died each year.

Chickenpox vaccine became available in the United States in 1995. Each year, more than 3.5 million cases of chickenpox, 9,000 hospitalizations, and 100 deaths are prevented by chickenpox vaccination in the United States. [2]

Epidemiology of Chickenpox

• Age – Primarily children, uncommon in adults in whom the disease tends to be more severe.
• Causative agent – Virus is identical to virus of herpes zoster and hence designated varicella zoster virus (V-Z virus).
• Transmission – Droplet discharges from air passages. May be direct skin contact or by recently contaminated utensils.
• Incubation period – 14 to 15 days.
• Period of infectivity –Patients are infectious 48 h before
• Onset of the vesicular rash, during the period of vesicle formation (which generally lasts 4–5 days) and until all vesicles are crusted. [1]

1. "Geospatial Epidemiology of chicken-pox disease in India between 2015-2021: A GIS based analysis" (2022): This study found 1269 chickenpox outbreaks (27,257 cases) in India between January 2015 and May 2021, with 31 confirmed deaths, mainly in Bihar and Uttar Pradesh.[9]
2. "A deep dive into chickenpox epidemiology and outbreaks: A retrospective study in a tribal-dominated district of Western India" (2023): This research reported 2554 clinical chickenpox cases in the Dadra & Nagar Haveli district between 2014 and 2022, with the most affected age group being 6-10 years old.[10]
3. "Age related seroprevalence of antibodies to varicella in india" (2000): While older, this study is still relevant for understanding the historical context of chickenpox epidemiology in India. It found a high susceptibility to varicella-zoster virus (VZV) infection in adolescents over 15 years old.[11]

Causes of Chickenpox

• Chickenpox infection is caused by the varicella-zoster virus.
• It can spread through direct contact with the rash.
• It can also spread when a person with the chickenpox coughs or sneezes and you inhale the air droplets. [3]

Risk factors of Chickenpox

• No history of chickenpox
• Not immunized for varicella
• Newborns, pre terms and infants born to unsensitized mothers
• Pregnancy
• Infants born at less than 28 weeks gestation or who weigh less than or equal to 1000 grams regardless of maternal immune status.
• Immunodeficient states:
  • Cancer patients
  • Use of immunosuppressant drugs (6)

Pathophysiology of Chickenpox

Chickenpox is contracted by the inhalation of aerosolized nasopharyngeal secretions from an infected host. The highly contagious nature of VZV explains the epidemics of chickenpox that spread through schools, as one child who is infected quickly spreads the virus to many classmates.

Transmission

• The mode of transmission is by inhalation of aerosolized nasopharyngeal secretions from an infected host.
• Chickenpox can also be spread from people with shingles by direct contact.
• Viral shedding occurs 1-2 days prior to development of the rash and continues until all their chickenpox blisters have formed scabs.
• Nosocomial transmission of Varicella-zoster virus (VZV) has also been reported.

Incubation Period

• The incubation period of chickenpox is typically from 14 to 16 days. However, the interval may vary from 10 to 21 days.

• The infectivity period begins 48 hours prior to the appearance of the rash and lasts till crusts appear.

Dissemination

• After initial inhalation of contaminated aerosolized droplets, the virus infects the conjunctivae and the mucosae of the upper respiratory tract.
• Viral proliferation occurs in regional lymph nodes of the upper respiratory tract 2-4 days after initial infection, and is followed by primary viremia. (6)

Sign & Symptoms of Chickenpox

1. Stage of Invasion or Prodromata

• Not constant headache, sore throat also fever for 24 hours.
• Prodromal rashes – Erythematous, scarlatiniform, morbilliform or urticarial. Additionally, Rarely hemorrhagic.

2. Stage of Eruption

Enanthem – Earliest lesions on buccal and pharyngeal mucosa.

Exanthem –

• Evolution – in crops; at first back, then chest, abdomen, face, and lastly limbs.
• Character – At first macule, in few hours’ dark pink papule which soon turns into vesicle –

(i) Firstly, superficial, i.e. ‘on’ rather than ‘in’ the skin (glass pox),

(ii) Secondly, elliptical or oval (“tear drop” vesicles) with axis parallel to ribs,

(iii) Lastly, unilocular, hence collapse if pierced with a needle. Additionally, Vesicles turn into pustules in 24 hours. Scabs in 2 to 5 days.

• Distribution – centripetal, i.e. more on upper arms and thighs and upper part of face, and in concavities and flexures. Less commonly lesions on genital mucous membranes, conjunctivae and cornea.
• Cropping – Rash matures very quickly and most spots dry up within 48 hours of appearance. But for 2-3 days’ new spots continue to appear so that on any area of the body vesicles, pustules and scabs are found side by side (in other words, Polymorphism). In immunocompromised patients both children and adults, particularly those with leukaemia have lesions (often with a hemorrhagic base) that are more numerous and take longer to heal than those of immunocompetent patients.

Other symptoms –

• Pruritus of varying degree.
• Generalized lymphadenopathy may occur and enlargement of sub occipital and posterior cervical lymph nodes from secondarily infected scalp lesions.
• Varicella hemorrhagica – Hemorrhages into vesicles, skin, subconjunctiva or from intestines. The complication is not due to overwhelming toxaemia as in smallpox but due to thrombocytopenia
• Varicella bullosa – Few or many of the lesions become bullous; common in children with impetigo.
• Varicella gangrenous – due to infection with hemolytic streptococcus producing the fulminating type, or with diphtheria bacillus causing the subacute type. Necrosis of lesions with toxaemia.
• Congenital and Neonatal chickenpox – Virus may pass through the placenta and the baby is born with chickenpox or develops it in neonatal period. [1]

Clinical examination of Chickenpox

Appearance of the Patient

• The patient appears weak and tired with rashes spread over the scalp, face, trunk, and limbs. The intense Pruritis triggers recurrent urges to scratch.

Vitals

• Low-grade fever
• Tachycardia

Skin

Skin lesions on physical examination include:

• Pruritic macules on the back, chest, face, abdomen and extremities.
• Skin lesions progress to papules and heal by crusting. Other common skin lesions include:
  • Papules
  • Vesicles
  • Pustules
  • Crusts

HEENT

• Cervical lymph nodes
• Pallor
• Skin lesions
• Oral ulcers

Lungs

Normal breath sounds are heard.

Abdomen

The abdomen will not be tender and there is no organomegaly.

Heart

• Normal S1 and S2 are heard.
• Ventricular fibrillation presumed to be secondary to myocarditis has been observed in some of the adult population. 

CNS

• The neurological examination may be normal with no focal neurological deficits.
• CNS may show the following findings:

• Meningitis
• Meningoencephalitis
• Vasculopathy (6)

Diagnosis of Chickenpox

In brief, the rash caused by chickenpox is usually enough for a doctor to diagnose it.

If there is any doubt about what is causing your rash, your doctor may conduct laboratory tests, including blood test or a culture of lesion samples.

Differential Diagnosis i.e. 

• Coxsackievirus
• Stevens-Johnson syndrome
• Kawasaki disease
• Measles
• Syphilis
• Rubella
• Cytomegalovirus
• Meningitis
• Molluscum contagiosum [5]

Complication 

• Bacterial infection of skin (usually group A streptococci or Staph. Aureus) causing impetigo, cellulitis and post inflammatory scarring.
• The most common extracutaneous site of involvement in children is the CNS.
• Rare in children. In adults the disease tends to be more severe and is more likely to be fulminant or complicated by pulmonary involvement
• Cellulitis or impetigo
• Pneumonia –

(a) Firstly, In children due to secondary infection ,

(b) Secondly, Pneumonitis

• Neurological complications – Post-varicella encephalitis more common in children than adults. Differs from other virus encephalitides because of predominance of cerebellar signs such as ataxia, vertigo, and nystagmus. Cranial nerve palsies particularly of oculomotor and facial nerves may develop. Reye’s syndrome, transverse myelitis and Guillain-Barre syndrome may also occur.
• Thrombocytopenia
• Congenital abnormalities – very rarely in first trimester of pregnancy in the form of scarred and atrophied limbs, microcephaly and ocular damage.
• In the immunocompromised child – Varicella is often severe and the rash and high fever continue for up to 2–3 weeks. Visceral involvement causing hepatitis, pneumonitis and encephalitis is common.

Investigation of Chickenpox 

In detail, A Tzazk smear, performed by scraping the base of an acute lesion and staining with Giemsa’s or Papanicolaou’s stain, may demonstrate multinucleated giant cells containing intranuclear inclusions. Addition, Other tests include fluorescent antibody against membrane antigen, immuno-adherence hemagglutination and enzyme-linked immunosorbent assay.

Treatment

• No need to confine patient to bed unless symptoms are severe.
• For pruritus – Calamine lotion with or without phenol (0.4%) and sedative antihistaminic by mouth. If there is much scabbing, gauze soaked in 1 in 5,000 solution of potassium permanganate which is changed every 4 hours may be applied to areas most affected.
• For secondary infection – e.g. Antibiotics.
• For true varicella pneumonia – Oxygen.
• For encephalitis – Oxygen also corticosteroids.
• Paracetamol for fever. Aspirin is contraindicated because of the association with Reye’s syndrome.
• Oral acyclovir initiated within 24h of rash results in a decrease in the duration and magnitude of the fever, and in the number and duration of skin lesions.

Prevention of Chickenpox

• There is no cure for chickenpox, but a vaccine is available for VZV. Today, the chickenpox vaccine is about 90%Trusted Source effective at preventing the disease for most people.
• People should avoid close contact with people known to have chickenpox, avoid sharing objects with them, isolate any household members with chickenpox from others, and disinfect surfaces an infected person may have touched. (7)

Homeopathic Treatment of Chickenpox

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

Which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines. 

Homeopathic Medicines for Chickenpox 

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath)

Medicines:

1. Aconitum:

• This homeopathic remedy responds best in the initial stages of chickenpox; especially when the patient suffers from symptoms like an increase of thirst, high fever, and weakness.
• It has generally a sudden high fever, agg at night.
• The pulse is hard, ample, bounding, unquenchable thirst for cold water only.

• The important characteristic is the anxiety with restlessness also fear of death.
• There co – exists often some digestive troubles, with white tongue, sometimes diarrhoea. [4]

2. Belladonna:

• Belladonna is an effective homeopathic medicine for treating chickenpox.
• This remedy is prescribed when the patient experiences symptoms like a red face, severe aches in head and body, drowsiness etc.
• Severe headache, face flushed, hot skin
• Drowsiness with inability to sleep.

3. Rhus Tox:

• This is an effective and common homeopathic remedy for treating chickenpox.
• Children who suffer from intense itching are generally prescribed this remedy.

4. Antinomian Crud:

• White coated tongue is the most common characteristic in children when this remedy is prescribed.
• Moreover, this remedy works well on the children who encounter symptoms like itching pimples and rashes from the exposure to heat right after a bath.

5. Apis:

• This homeopathic remedy for chickenpox is advised when children experience severe itching from heat and feel relieved in the exposure to cool places.[4]

Diet & Regimen

• A diet for chickenpox should be filled with soft, cool, bland, non-alcoholic foods also plenty of water
• Staying hydrated
• Plain water
• Coconut water
• Herbal tea
• Low-sugar sports drinks
• Electrolyte infused drinks

References use for Article 

1.  Medicine Golwala.
2. https://www.cdc.gov/chickenpox/about/index.html#:~:text=Chickenpox%20is%20a%20highly%20contagious,250%20and%20500%20itchy%20blisters
3.  https://www.mayoclinic.org/diseases-conditions/chickenpox/symptoms-causes/syc-20351282#:~:text=Chickenpox%20infection%20is%20caused%20by,you%20inhale%20the%20air%20droplets.
4. https://www.lybrate.com/topic/homeopathy-treatment-for-chickenpox/4aa6be7b0efe994cfabf6b0bb81d809c
5. https://www.wikidoc.org/index.php/Chickenpox_differential_diagnosis
6. Clinical examination
7. https://www.medicalnewstoday.com/articles/239450#prevention
8. https://www.google.com/search?q=types+of+chicken+pox&newwindow
9. Geospatial Epidemiology of chicken-pox disease in India between 2015-2021: A GIS based analysis (2022)
10. A deep dive into chickenpox epidemiology and outbreaks: A retrospective study in a tribal-dominated district of Western India (2023)
11. Age related seroprevalence of antibodies to varicella in india (2000)
12. Medical Microbiology (8th Edition) by Murray, Rosenthal, and Pfaller (2016)

13. Jawetz, Melnick & Adelberg’s Medical Microbiology (28th Edition) by Brooks, Carroll, Butel, Morse, and Mietzner (2019)

14. Principles and Practice of Pediatric Infectious Diseases (5th Edition) by Long, Pickering, and Prober (2018)

15. Nelson Textbook of Pediatrics (21st Edition) by Kliegman, St. Geme, Blum, Shah, Tasker, and Wilson (2020)
16. Harrison’s Principles of Internal Medicine (20th Edition) by Jameson, Fauci, Kasper, Hauser, Longo, and Loscalzo (2018)
17. Red Book: 2021 Report of the Committee on Infectious Diseases (32nd Edition) by the American Academy of Pediatrics (2021)
18. The Vaccine Book by Dr. Robert W. Sears (2011)
19. Caring for Your Baby and Young Child: Birth to Age 5 (7th Edition) by the American Academy of Pediatrics (2020)