eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Varicella: Differential Diagnoses & Workup
Updated: Jul 31, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Contact Dermatitis
Enteroviral Infections
Herpes Simplex Virus Infection
Impetigo
Urticaria
Other Problems to Be Considered
Drug reactions
Insect bites
Smallpox
Workup
Laboratory Studies
- Laboratory studies are unnecessary for diagnosis because varicella is clinically obvious.
- Most children with varicella have leukopenia in the first 3 days, followed by leukocytosis.
- Marked leukocytosis may indicate a secondary bacterial infection but is not a dependable sign. Most children with significant secondary bacterial infections do not have leucocytosis.
- Immunohistochemical staining of skin lesion scrapings can confirm varicella.
- The procedure is useful for high-risk patients who require rapid confirmation.
- A Tzanck smear involves scraping the base of the lesions and then staining the scrapings to demonstrate multinucleated giant cells. However, this finding is not sufficiently sensitive or specific for varicella and should be replaced by the more specific immunohistochemical staining of such scrapings, if available.
- Serologic studies include the following:
- Serology is mainly used to confirm past infection to assess a patient's susceptibility status. This helps determine preventive treatment requirements for an adolescent or adult who has been exposed to varicella.
- Among the many serologic studies, the most sensitive are the indirect fluorescent antibody (IFA), fluorescent antibody to membrane antigen (FAMA), neutralization test (NT), and radioimmunoassay (RIA). These time-consuming tests require specialized equipment that renders them unsuitable for routine use.
- Commercially available latex agglutination (LA) and enzyme-linked immunosorbent assay (ELISA) tests are sensitive and rapid. Although the complement fixation test is often used, its sensitivity is low.
Imaging Studies
- Chest radiography
- Children with high temperatures and respiratory signs should have chest radiography to confirm or exclude pneumonia.
- Chest radiographic findings may be normal or may show diffuse bilateral nodular infiltrates in primary varicella pneumonia.
- Radiography may also detect focal infiltrates suggestive of secondary bacterial pneumonia.
Other Tests
- Lumbar puncture
- Children with neurological signs should have their cerebrospinal fluid (CSF) examined.
- The CSF of patients with varicella encephalitis may have few or as many as 100 cells that are polymorphonuclear or mononuclear, depending on the timing of the lumbar puncture.
- Glucose levels are within the reference range.
- Protein levels are within the reference range or are slightly elevated.
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References
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[Guideline] Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine. MMWR Morb Mortal Wkly Rep. Mar 14 2008;57(10):258-60. [Medline].
Matsukura H, Murakami M, Sakaki H, Mitani T, Shimura S. Varicella glomerulonephritis preceding the cutaneous lesions. Clin Nephrol. Aug 2009;72(2):161-2. [Medline].
Arbeter AM, Granowetter L, Starr SE, et al. Immunization of children with acute lymphoblastic leukemia with live attenuated varicella vaccine without complete suspension of chemotherapy. Pediatrics. Mar 1990;85(3):338-44. [Medline].
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CDC. National, state, and urban area vaccination coverage among children aged 19-35 months--United States, 2004. MMWR Morb Mortal Wkly Rep. Jul 29 2005;54(29):717-21. [Medline]. [Full Text].
Chaves SS, Gargiullo P, Zhang JX, et al. Loss of vaccine-induced immunity to varicella over time. N Engl J Med. Mar 15 2007;356(11):1121-9. [Medline].
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Galil K, Lee B, Strine T, et al. Outbreak of varicella at a day-care center despite vaccination. N Engl J Med. Dec 12 2002;347(24):1909-15. [Medline]. [Full Text].
Jaamaa S, Salonen M, Seppala I, et al. Varicella zoster and Borrelia burgdorferi are the main agents associated with facial paresis, especially in children. J Clin Virol. Jul 2003;27(2):146-51. [Medline].
Pastuszak AL, Levy M, Schick B, et al. Outcome after maternal varicella infection in the first 20 weeks of pregnancy. N Engl J Med. Mar 31 1994;330(13):901-5. [Medline]. [Full Text].
Verstraeten T, Jumaan AO, Mullooly JP, et al. A retrospective cohort study of the association of varicella vaccine failure with asthma, steroid use, age at vaccination, and measles-mumps-rubella vaccination. Pediatrics. Aug 2003;112(2):e98-103. [Medline]. [Full Text].
Zhou F, Harpaz R, Jumaan AO, et al. Impact of varicella vaccination on health care utilization. JAMA. Aug 17 2005;294(7):797-802. [Medline]. [Full Text].
Further Reading
Keywords
varicella, chickenpox, chicken pox, waterpox, water pox, varicellovirus, varicella-zoster virus, varicella pneumonia, varicella encephalitis, group A streptococcal disease, Reye syndrome, congenital varicella syndrome, growth retardation, microcephaly, cortical atrophy, limb hypoplasia, microphthalmia, cataracts, chorioretinitis, infantile zoster, neonatal varicella, maternal varicella, diagnosis, treatment
