Pediatric Chickenpox Workup

  • Author: Kirsten A Bechtel, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Sep 28, 2011
 

Approach Considerations

In general, laboratory studies are unnecessary for diagnosis, because varicella is clinically obvious. However, some tests and procedures may be helpful in confirming the diagnosis or identifying complications. Imaging studies are typically not required for varicella unless secondary complications are a concern (eg, chest radiography for varicella pneumonia).

Go to Chickenpox for complete nonpediatric information on this topic.

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Blood Studies

White blood cell count

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 leukocytosis; neutrophilic leukocytosis and neutrophilia occur in only a few cases involving serious bacterial infections. Investigations cannot be relied on to diagnose or exclude bacterial infection.

Alanine aminotransferase level

Significant elevations of alanine aminotransferase (ALT) occur in 20-50% of children and adolescents with varicella complicated by hepatitis, but elevations return to normal within one month in almost all cases.

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Staining

Tzanck smear

A Tzanck smear involves scraping the base of the lesions and then staining the scrapings to demonstrate multinucleated giant cells. The presence of multinucleated giant cells suggests a herpes virus infection but is not specific for varicella-zoster virus. Infections with other herpes viruses, such as herpesvirus 1 and 2, also display similar multinucleated giant cells. Thus, 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.

Immunohistochemical staining

Immunohistochemical staining of skin lesion scrapings can confirm varicella. The procedure is useful for high-risk patients who require rapid confirmation.

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Serologic Studies

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.

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Polymerase Chain Reaction

Polymerase chain reaction (PCR) examination of skin scrapings is quick and sensitive. This test is replacing other methods as the equipment becomes more widely available.

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Culture

Bacterial culture of lesions may be indicated if signs of superinfection are present.

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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.

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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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Contributor Information and Disclosures
Author

Kirsten A Bechtel, MD  Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

Archana Chatterjee, MD, PhD  Professor of Pediatrics, Medical Microbiology and Immunology, and Pharmacy, Division of Pediatric Infectious Diseases, Chief of Division of Pediatric Infectious Diseases, Creighton University School of Medicine; Hospital Epidemiologist and Medical Director of Infection Control, Children's Hospital

Archana Chatterjee, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, International Society for Infectious Diseases, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Richard Lichenstein, MD  Associate Professor, Pediatric Emergency Department, University of Maryland School of Medicine

Richard Lichenstein, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association

Disclosure: Nothing to disclose.

Parang N Mehta, MD  Consulting Staff, Department of Pediatrics, Mehta Hospital, Surat, India

Parang N Mehta, MD is a member of the following medical societies: Indian Academy of Pediatrics and Indian Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Leonard R Krilov, MD  Chief of Pediatric Infectious Diseases and International Adoption, Vice Chair, Department of Pediatrics, Professor of Pediatrics, Winthrop University Hospital

Leonard R Krilov, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Medimmune Grant/research funds Cliinical trials; Medimmune Honoraria Speaking and teaching; Medimmune Consulting fee Consulting

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Leslie L Barton, MD  Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

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The pleomorphic rash characteristic of varicella. Papules, vesicles, and pustules are concurrently present.
Papulovesicular lesions on arm in varying stages of healing in this infant with varicella. Photograph courtesy of Susan Feigelman, MD.
 
 
 
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