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CHICKENPOX IN CHILDREN
Abdulloev Mukhriddin Ziedulloevich
https://orcid.org/0009-0005-2297-5516
Bukhara State Medical Institute named after Abu Ali ibn Sina, Uzbekistan,
Bukhara, A. Navoi St. 1 Phone number: +998 (65) 223-00-50 e-mail:
Summary. The article discusses questions of an etiopathogenesis, treatment
and prevention of chicken pox which is a widespread infection in children. This
article gives classical and atypical clinical manifestations and also registered
complications of chicken pox.
Keywords: with hicken pox, herpes-viral infection, virus, children
Chickenpox is an anthropozoonotic acute viral infection accompanied by
intoxication and damage to the epithelium of the skin and mucous membranes in the
form of a maculopapular -vesicular rash.
Chickenpox was first described by the Italian physician and anatomist G.
Vidus ( Vidius ) in the mid-16th century. The name varicella , distinguishing the
disease from smallpox ( variola ), was introduced by the German physician O. Vogel
(1772), and after the epidemic of 1868–1874, the disease began to be considered a
separate nosological form. In 1911, the Brazilian physician E. Aragao discovered
elementary bodies of the virus ( Aragao bodies ) in the contents of vesicles, and the
virus was isolated from them in the 1940s.
The causative agent of chickenpox ( Herpes zoster ) is a DNA virus classified
as human herpesvirus type 3, included in the family Herpesviridae , subfamily Alpha
herpesviridae . This virus is present in large quantities in chickenpox blisters during
the first 3-4 days of the disease, then its quantity rapidly decreases, and after the 7th
day it cannot be detected. At present, the identity of the virus that causes shingles
and the chickenpox virus has been established. The virus lives and reproduces only
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in the human div, it is extremely volatile (it can spread with air over distances of
up to 20 meters, overcoming ventilation systems, elevator shafts and stairwells).
Chickenpox is a ubiquitous and highly contagious disease with a 100%
susceptibility rate. This infection primarily affects children aged 1 to 10 years (75–
85% of cases), with the peak incidence occurring at 3–4 years of age, and by the age
of 15, about 80–90% of the population has had chickenpox. Before the introduction
of the vaccine, about 4 million cases of the infection were registered each year.
Currently, worldwide, the incidence and hospitalization rates due to chickenpox
have decreased by almost 90%, which is due to the introduction of vaccination [1,
5].
The incidence among the urban population is almost 2 times higher than that
among rural residents. The infection is characterized by autumn-winter seasonality,
and the incidence during seasonal increases is approximately 70-80% of the total
number of patients [1, 6]. The source of infection is patients with chickenpox and
shingles. Patients with chickenpox become contagious at the end of the incubation
period (48 hours before the rash appears) and continue to pose a danger to others
until the 5th day after the last element of the rash appears. The virus is transmitted:
1) by airborne droplets - when talking, sneezing, coughing, kissing; 2) by contact -
when the patient's saliva or the contents of the blisters come into contact with
unaffected skin; 3) transplacentally - from a pregnant mother to the fetus, if the
woman falls ill with either chickenpox or shingles during this period.
After the disease, immunity is maintained for life in 97% of the population,
the remaining 3% can get sick again. People with normal immunity get chickenpox
only once, since after the first case of the disease, an "immune memory" is formed
in their div, which lasts for life and does not allow this disease to develop again.
However, people with a severely weakened immune system can get chickenpox
twice (repeatedly). The resistance of newborns to chickenpox is due to antibodies
received from the mother, which circulate for up to 6 months.
After the disease, the virus can remain in the div in a latent state for life,
localizing in the nerve ganglia. However, in some people it reactivates , causing the
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appearance of a painful rash on the skin of different areas of the div, as with
chickenpox or simple herpes, which is localized along the nerve trunks (shingles).
Unfortunately, the mechanisms of virus preservation and its possible subsequent
activation with manifestations of the disease in the form of shingles have not been
sufficiently studied.
The entry point for infection is the mucous membrane of the upper
respiratory tract. Multiplying on the mucous membranes, the virus enters the blood
at the end of the incubation period, causing viremia . The virus is carried throughout
the div by the bloodstream, the pathogen is fixed mainly in the epithelium of the
skin and mucous membranes, where, multiplying, it leads to the appearance of a rash
pathognomonic of chickenpox. In the early stages, the nuclei of the affected cells
contain spherical eosinophilic inclusions ( Tizzer bodies ). In the process of nuclear
degeneration, these bodies enter the cytoplasm. Cellular vacuoles quickly merge
with adjacent ones, forming a vesicle. Initially, the vesicle is multi-chambered and
consists of small cavities separated from each other by cellular cords, which
subsequently quickly rupture due to the filling of the vesicles with liquid. The
Malpighian layer is mainly affected. Changes in the mucous membranes are of the
same nature as in the epidermis. The rash elements on the mucous membranes in
chickenpox do not leave scars, since epithelial necrosis in chickenpox usually does
not penetrate deeper than the germinal layer [5].
It should be remembered that the virus is not only dermatotropic , but also
neurotropic , which is manifested in its ability to cause damage to the nervous
system. In rare cases, damage to internal organs (liver, kidneys, lungs, central
nervous system) is observed. Generalized forms of chickenpox develop in weakened
children with an altered immune state (due to long-term treatment with hormones,
cytostatics , with congenital or acquired immunodeficiency, etc.).
Disturbances in cellular immune responses are of great importance in the
pathogenesis of the disease. Reproduction of the virus in lymphocytes, neutrophils,
monocyte-macrophages leads to immunodeficiency of the T-cell type. The
mechanisms of immunosuppressive action are due to the suppression of chemotaxis
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and a decrease in the activity of the phagocytosis process, inhibition of the function
of T-killers, natural killers (NK), the reaction of lymphocyte blast transformation,
and possible direct stimulation of T-suppressors. Interferon deficiency also plays a
significant role in the pathogenesis of chickenpox , which is manifested in the
suppression of the interferon reaction of leukocytes, a decrease in the ability of
lymphocytes to synthesize gamma interferon, and fibroblasts - beta interferon.
Against the background of suppression of the T-lymphocyte system in
individuals with impaired immune status, severe forms of chickenpox develop, and
with the development of anergy in patients with chickenpox, susceptibility to other
infections increases.
The indicated pathogenetic and immunological features of the development
and course of chickenpox must be taken into account when treating patients.
Clinical manifestations
During chickenpox, there are 4 periods: incubation, prodromal, periods of
rash and crust formation. The incubation period is 11-21 days. Prodromal
phenomena can be observed for 1-2 days before the onset of the rash. In this case,
the patient feels unwell, appetite decreases, headache, nausea, and sometimes
vomiting occur. If the prodromal period is absent, the disease begins with the
appearance of a rash. The period of rash in most patients proceeds without any
particular disturbances in the general condition. Fever coincides with the period of
rash appearance. The rash appears in spurts, so the fever can be wave-like. The first
elements of the rash can appear on any part of the div, but most often on the face,
scalp, back, less often on the abdomen, chest, shoulders, thighs. As a rule, there is
no rash on the palms and soles. In this case, the presence of rash elements on the
scalp is pathognomonic. The elements of chickenpox go through the following
stages of development: spots, papules, vesicles, crusts ("false polymorphism"). At
first, a red spot appears, the size of a pinhead to a lentil, round or oval in shape.
Within a few hours, the spots acquire the character of papules with a clearly defined
contour, and after a few more hours or the next day, a vesicle-bubbles with smooth
edges and transparent serous contents forms in the center of the elements. In the case
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of suppuration of vesicles, pustules are formed, with deep damage to the skin, which
can lead to the formation of small depressions in the center of the pustules, which
leave scars. Rashes are often observed on the conjunctiva of the eyes, the mucous
membrane of the mouth (hard palate, mucous membrane of the cheeks, gums, uvula,
back wall of the pharynx), sometimes the larynx and genitals. Chickenpox is
characterized by multiple rashes that appear in several stages, sequentially, over 2–
5 days. Such a wave-like rash leads to the fact that on the same limited area of skin,
elements of chickenpox are noted that are at different stages of development, which
gives the rash a polymorphic character.
Depending on the course of the disease, clinical forms of chickenpox are
distinguished - typical and atypical. Among the atypical, rudimentary, hemorrhagic,
bullous, gangrenous and generalized rash should be noted.
The rudimentary form occurs without a rash or with a scanty rash, while the
elements of the rash do not reach their full development, being limited only to the
appearance of small red spots. Sometimes the rash may consist of only a few papules
and small, barely noticeable blisters, while the polymorphism of the rash is weakly
expressed.
In the hemorrhagic form, on the 2nd-3rd day of the disease, the rash shows
accumulation of hemorrhagic contents in the vesicles with the simultaneous
appearance of petechiae and large hemorrhages on the skin and mucous membranes.
Bleeding from the gums, nose and gastrointestinal tract is possible. The crust that
forms in this form is black, deep in the skin, and often ulcerates. This form is usually
observed in patients with previous hemorrhagic phenomena - with capillary
toxicosis , Werlhof's disease [2].
In the bullous form, along with typical chickenpox blisters, large, flaccid,
thin-walled blisters with yellowish-cloudy contents are observed on the skin, which
dry out more slowly than usual and form a crust or, bursting, turn into long-term
non-healing weeping surfaces. In the bullous form, independently formed blisters,
quickly increasing in size along the periphery, can merge into large blisters.
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The gangrenous form is characterized by progressive necrosis. Several days
after the appearance of vesicles, gangrenous rims appear around some of them,
spreading along the periphery. The vesicles are round, large, several centimeters in
diameter, filled with purulent-bloody contents. After opening, a necrotic scab forms
in their place, and when it is rejected, long-healing ulcers of varying depths with
undermined edges and a dirty purulent bottom are found. This form is characterized
by severe intoxication and high mortality. The gangrenous form is rare, mainly in
children with reduced reactivity of the div.
The generalized (visceral) form occurs during treatment with steroid
hormones, in people weakened by serious illnesses. It is characterized by damage to
internal organs. The course of the disease is very severe, often with a fatal outcome.
According to the severity of the disease, it can be mild, moderate or severe
(a – with pronounced general intoxication; b – with pronounced changes in the skin).
Chickenpox is considered a benign disease, but in some cases complications
may develop (in about 5-10%), sometimes very severe, which we sometimes observe
in our patients. Among the complications of chickenpox, the most common are
various purulent skin lesions: abscesses, furuncles, phlegmon. Purulent skin
complications are based on superinfection with staphylococci or streptococci. One
of the common causes of infection is scratching itchy skin areas by the patient. In
most cases, the entry point for purulent infection is a damaged chickenpox vesicle.
Less common complications: encephalitis, myocarditis, pneumonia, keratitis,
nephritis, arthritis, hepatitis.
Clinically expressed picture of chickenpox pneumonia is one of the features
of chickenpox in adolescents and adults. In this case, often simultaneously with mass
rash and fever, the patient develops shortness of breath, cyanosis, cough with bloody
sputum, chest pain. Physical changes are usually absent or very minor. The
radiograph shows abundant small foci throughout. Clinical manifestations of
pneumonia are observed for 7-10 days, radiographic changes - up to 1-2 months.
Encephalitis develops in 0.1–0.2% of children with chickenpox [6].
Chickenpox encephalitis or meningoencephalitis can develop in the first days of the
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disease (early) or (more often) during the period of crust formation (late). With late
encephalitis, the patient develops lethargy, headache, vomiting, and the temperature
rises again. The child's gait becomes unsteady, he cannot stand or sit, and complains
of dizziness (cerebellar ataxia). His speech becomes dysarthric , quiet, slow.
Convulsions and loss of consciousness are possible. Syndrome
Reye's syndrome (acute hepatic encephalopathy) is currently a rare but very
dangerous condition that occurs in children and adolescents during treatment of viral
fever (flu, chickenpox) with drugs containing acetylsalicylic acid (Aspirin), and is
characterized by rapidly progressing encephalopathy (due to cerebral edema) and
the development of fatty liver infiltration. Symptoms (rash, vomiting, confusion)
appear approximately a week after the onset of the disease. In the laboratory, Reye's
syndrome is characterized by an increase in the level of ALT, AST, urea, ammonia,
prothrombin index with a normal bilirubin content.
Unlike Reye's syndrome, chickenpox hepatitis is usually asymptomatic and
is characterized by increased activity of liver enzymes, especially ALT and AST .
Age-related features of chickenpox
In newborns and children of the first year of life (especially if the mother has
not had chickenpox), the course of the disease has certain characteristics. From the
first days, general infectious symptoms are detected: weakness, subfebrile div
temperature, anorexia, sometimes vomiting, frequent stools. A profuse rash,
appearing on the 2nd-5th day of the disease, can acquire a hemorrhagic character.
During the rash, the div temperature is high, significant toxicosis, convulsions, loss
of consciousness are possible. Often, a layering of secondary bacterial infection and
the development of purulent foci of inflammation (pyoderma, phlegmon,
pneumonia, etc.) are observed. If a woman is infected in the first months of
pregnancy, a teratogenic effect of the virus on the fetus is possible, however, the
birth of children with embryo- and fetopathies associated with chickenpox is very
rare. According to modern studies, if infection occurs during the 1st or 2nd trimester
of pregnancy, the spread of the virus to the fetus occurs in about 25% of cases. At
the same time, the negative impact of the virus on the development of the fetus and
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the occurrence of developmental defects in children is observed in less than 1-3% of
cases. The chickenpox virus can cause developmental disorders of the eyes, limbs,
and developmental disorders of the bones of the skull and brain in the fetus. Some
children develop only one of these defects, while others develop several or all [7].
According to literature, if a woman gets chickenpox shortly before giving
birth (1–4 weeks) or 1–2 days after giving birth, then in 20–50% of cases the
newborn child will also get sick. Due to the fact that this infection can develop
aggressively in newborns, about 7% of newborns who get chickenpox die [7].
If a woman falls ill in the last days of pregnancy, congenital chickenpox is
possible. This includes all cases of the disease that occur in a newborn up to 11 days
old. The severity of the disease is determined by the time of infection. If a woman
falls ill immediately before giving birth, chickenpox in a child appears on the 5th-
10th day of life, has a severe course and often leads to the death of the child due to
the generalization of the infection and damage to internal organs. If a woman falls
ill 5-10 days before giving birth, the first clinical signs of the disease in the newborn
appear immediately after birth. The course of chickenpox in these cases is milder,
since the mother has time to develop specific antibodies that are transmitted to the
fetus transplacentally [7].
In typical cases, diagnostics of chickenpox is not difficult. The diagnosis is
established mainly on the basis of clinical features, taking into account the data of
the epidemiological anamnesis. Laboratory methods that can be used include
viroscopic , virological, molecular biological and serological analysis.
Treatment is carried out mainly at home. Only patients with complicated and
severe cases of the disease, patients from risk groups, and those who cannot be
isolated are subject to hospitalization.
The basis of treatment is compliance with hygiene measures aimed at
preventing secondary infection. Clothes and bed linen should be changed every day;
to avoid scratching, nails should be carefully, neatly and promptly cut (for children,
put cotton mittens on their hands); a child with chickenpox can and should be bathed
every day, but it is strictly forbidden to rub the skin with a sponge or washcloth; after
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bathing, you cannot wipe the child's div, but only gently blot it, since the crusts get
soaked in water, which can become a threat of additional infection.
The rash that appears with chickenpox does not require any special
treatment. Previously used locally aniline dyes (1% aqueous solutions of methylene
blue or brilliant green) are not used today to treat chickenpox, which is due to both
the growing resistance of a number of microorganisms to their action, and the
unaesthetic nature of their use (traces of applying solutions to the skin remain for a
long time, they tint clothes). In recent years, specialists around the world have
recommended locally applying ointments (gels) with zinc (for example, Curiosin
gel) for drying purposes, and ointments with an antibiotic for antimicrobial action.
If the oral mucosa is affected, rinse with antiseptic solutions; damage to the
conjunctiva threatens serious complications, so it is necessary to involve an
ophthalmologist in the treatment.
Of course, most of the measures are aimed at preventing skin scratching and
reducing itching. For this purpose, you can use first-generation antihistamines
(fenkarol, suprastin), which have an antipruritic effect. In addition, symptomatic
therapy is prescribed (antipyretic drugs). tva ).
Indications for the appointment of specific (antiviral) therapy with acyclic
nucleosides (acyclovir, foscarnet , famciclovir , valacyclovir ) are severe and
complicated forms of chickenpox.
Considering that in most cases of chickenpox hospitalization and specific
etiotropic therapy are not required, it is justified to use drugs containing interferons
or their inducers, which have antiviral activity against the H. zoster virus, for the
treatment of patients at the outpatient stage .
One of the drugs that has proven its effectiveness in the treatment of
chickenpox in children is inosine pranobex ( Groprinosin ), which has
immunostimulating activity and non-specific direct antiviral action. The drug
restores the functions of lymphocytes under immunodepression, increases
blastogenesis in the population of monocytic cells, stimulates the expression of
membrane receptors on the surface of T-helpers, has a stimulating effect on the
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activity of cytotoxic T-lymphocytes and natural killers, the functions of T-
suppressors and T-helpers, increases the production of immunoglobulin G,
interferons, interleukins (IL-1 and IL-2), reduces the formation of proinflammatory
cytokines (IL-4 and IL-10), potentiates the chemotaxis of neutrophils, monocytes
and macrophages.
The mechanism of the antiviral action of the drug is associated with the
inhibition of viral RNA and the enzyme dihydropteroate synthetase , which is
involved in replication, enhancing the synthesis of lymphocyte RNA suppressed by
viruses, which is accompanied by the inhibition of the biosynthesis of viral RNA
and the translation of viral proteins. The drug is most effective when prescribed
early, when there is a risk of the virus entering the div, or in the first two days of
the disease. For chickenpox, Groprinosin is prescribed to children at a daily dose of
50 mg / kg (1 tablet for every 10 kg of div weight) in 3-4 doses for 10-14 days
(until the symptoms disappear). Currently, a number of countries are vaccinating
against chickenpox among people belonging to risk groups (Austria, Belgium,
Finland, Poland, etc.).
Of course, such immunization tactics do not allow to significantly reduce the
incidence of chickenpox in general, but provide individual protection for the most
vulnerable groups. In other countries (USA, Canada, Germany, etc.), vaccination
against chickenpox is carried out within the framework of National Immunization
Calendars, which allows to reduce the incidence of chickenpox among the
population quite quickly [4, 8].
The vaccine can also be used for emergency prevention (after contact with a
patient with chickenpox) to prevent outbreaks. If the vaccination is given no later
than the 3rd day after probable contact, the infection can be prevented in 90% of
cases. According to research , the vaccine provides sufficient protection against
chickenpox and its complications. Of course, people who have been vaccinated can
get chickenpox, but the disease will be mild. Vaccination is recommended for
children aged 12 months and older, as well as adolescents and adults who have not
previously had chickenpox and have not been vaccinated [8].
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