Approach Considerations

The workup for chickenpox includes a Tzanck smear, vesicular fluid culture, serologic testing, chest radiography, and histologic examination.

Tzanck Smear

A Tzanck smear of vesicular fluid, which can be prepared in an office setting, demonstrates multinucleated giant cells and epithelial cells with eosinophilic intranuclear inclusion bodies.^[21]

Culture

Isolation of the varicella-zoster virus (VZV) through culture of vesicular fluid provides a definitive diagnosis; however, culturing for VZV is technically difficult, and cultures are positive less than 40% of the time. Direct immunofluorescence study offers excellent sensitivity and is more rapid than tissue culture. Polymerase chain reaction-based techniques are highly sensitive in identifying VZV, but they are not readily available.^[22]

Serology

Serologic evidence of immunity (native immunoglobulin G formation) to VZV can be achieved through a number of different assays, including the following:

Enzyme immunoassay
Indirect fluorescent antibody
Complement fixation
Fluorescent antibody to membrane assay
Latex agglutination test

Enzyme immunoassay, fluorescent antibody to membrane assay, and indirect fluorescence are not widely available, and complement fixation is not highly sensitive for VZV. The latex agglutination test is the most popular serologic assay for determining exposure and immunity to VZV.

Chest Radiography

Chest radiography is indicated for adults who are experiencing pulmonary symptoms of chicken pox.

Histologic Findings

Histologic examination of skin lesions does not differentiate VZV from herpes simplex virus (HSV) infection. Intranuclear eosinophilic inclusion bodies are seen in epithelial cells in both infections. Leukocytoclastic vasculitis and hemorrhage are more common in VZV lesions than HSV, however, and both immunohistochemistry and direct fluorescent antibody testing can be used to differentiate between the infections.^[23]

Treatment & Management

Okamoto A, Abe A, Okamoto M, et al. A varicella outbreak in B-cell lymphoma patients receiving rituximab-containing chemotherapy. J Infect Chemother. 2014 Aug 30. [QxMD MEDLINE Link].
Czumbel I, Quinten C, Lopalco P, Semenza JC, ECDC expert panel working group. Management and control of communicable diseases in schools and other child care settings: systematic review on the incubation period and period of infectiousness. BMC Infect Dis. 2018 May 2. 18 (1):199. [QxMD MEDLINE Link].
Bruno J, Ragozzino S, Quitt J, et al. Severe acute respiratory syndrome coronavirus 2, primary varicella zoster virus coinfection, and a polymicrobial ventilator-associated tracheobronchitis in an adult immunocompetent male: a case report. J Med Case Rep. 2022 Jan 24. 16 (1):45. [QxMD MEDLINE Link]. [Full Text].
Xu R, Zhou Y, Cai L, Wang L, Han J, Yang X, et al. Co-Reactivation of Human Herpesvirus alpha Subfamily (HSV Ⅰ and VZV) in Critically Ill Patient with COVID-19. Br J Dermatol. 2020 Aug 13. [QxMD MEDLINE Link].
Shieh C, Barnes A, Johnson DM, Danelich IM, Pirlamarla P, Alvarez R, et al. Atypical Reactivation of Varicella Zoster Virus Associated with Pancreatitis in a Heart Transplant Patient. Am J Case Rep. 2020 Aug 12. 21:e923969. [QxMD MEDLINE Link].
Almutairi A, Alfaleh M, Alasheikh M. Dermatological Manifestations in Patients With SARS-CoV-2: A Systematic Review. Cureus. 2020 Jul 28. 12 (7):e9446. [QxMD MEDLINE Link].
Choo PW, Donahue JG, Manson JE, Platt R. The epidemiology of varicella and its complications. J Infect Dis. 1995 Sep. 172(3):706-12. [QxMD MEDLINE Link].
Nguyen HQ, Jumaan AO, Seward JF. Decline in mortality due to varicella after implementation of varicella vaccination in the United States. N Engl J Med. 2005 Feb 3. 352(5):450-8. [QxMD MEDLINE Link].
Bozzola E, Guolo S, Macchiarulo G, Festa L, Spina G, Krzysztofiak A, et al. Hospitalization for acute cerebellitis in children affected by varicella: how much does it cost?. Ital J Pediatr. 2020 Aug 6. 46 (1):114. [QxMD MEDLINE Link].
Aebi C, Ahmed A, Ramilo O. Bacterial complications of primary varicella in children. Clin Infect Dis. 1996 Oct. 23(4):698-705. [QxMD MEDLINE Link].
Higuchi S, Toichi E, Kore-eda S, et al. An adult case of Fournier's gangrene preceded by varicella. Acta Dermatol Kyoto. 1997. 92(4):375-80.
Austin TA, Steele RW. Eczema Varicella/Zoster (Varicellicum). Clin Pediatr (Phila). 2017 Jan 1. 9922816687332. [QxMD MEDLINE Link].
Miller HC, Stephan M. Hemorrhagic varicella: a case report and review of the complications of varicella in children. Am J Emerg Med. 1993 Nov. 11(6):633-8. [QxMD MEDLINE Link].
Forrest J, Mego S, Burgess M. Congenital and neonatal varicella in Australia. J Paediatr Child Health. 2000 Apr. 36(2):108-13. [QxMD MEDLINE Link].
Auriti C, Piersigilli F, De Gasperis MR, Seganti G. Congenital Varicella Syndrome: Still a Problem?. Fetal Diagn Ther. 2009 May 27. 25(2):224-229. [QxMD MEDLINE Link].
Tsunoda T, Ogawa S. A consideration on the distribution of eruption of herpes zoster. Acta Dermatol Kyoto. 1986. 81:95-8.
Schwartz RA, Jordan MC, Rubenstein DJ. Bullous chickenpox. J Am Acad Dermatol. 1983 Aug. 9(2):209-12. [QxMD MEDLINE Link].
Lunghi F, Finzi M. Varicella bullosa in HIV+ adults. Chronica Dermatologica (Roma). 1997. 7:557-60.
Hirota T, Hirota Y, Ichimiya M, et al. Atypical varicella seen in a woman with atopic dermatitis. Acta Dermatol Kyoto. 1998. 93(1):65-8.
Mazzara C, Milani GP, Lava SAG, et al. Atypical primary varicella rash: Systematic literature review. Acta Paediatr. 2022 May. 111 (5):935-939. [QxMD MEDLINE Link].
Nahass GT, Goldstein BA, Zhu WY, Serfling U, Penneys NS, Leonardi CL. Comparison of Tzanck smear, viral culture, and DNA diagnostic methods in detection of herpes simplex and varicella-zoster infection. JAMA. 1992 Nov 11. 268(18):2541-4. [QxMD MEDLINE Link].
Harbecke R, Oxman MN, Arnold BA, et al. A real-time PCR assay to identify and discriminate among wild-type and vaccine strains of varicella-zoster virus and herpes simplex virus in clinical specimens, and comparison with the clinical diagnoses. J Med Virol. 2009 Jul. 81(7):1310-22. [QxMD MEDLINE Link].
Molina-Ruiz AM, Santonja C, Rutten A, Cerroni L, Kutzner H, Requena L. Immunohistochemistry in the Diagnosis of Cutaneous Viral Infections-Part I. Cutaneous Viral Infections by Herpesviruses and Papillomaviruses. Am J Dermatopathol. 2014 Aug 28. [QxMD MEDLINE Link].
Chartrand SA. Varicella vaccine. Pediatr Clin North Am. 2000 Apr. 47(2):373-94. [QxMD MEDLINE Link].
Durrheim DN. Varicella vaccine: local convenience or global equity?. Lancet. 2006 Dec 23. 368(9554):2208-9. [QxMD MEDLINE Link].
Kamiya H, Ito M. Update on varicella vaccine. Curr Opin Pediatr. 1999 Feb. 11(1):3-8. [QxMD MEDLINE Link].
Vazquez M, Shapiro ED. Varicella vaccine and infection with varicella-zoster virus. N Engl J Med. 2005 Feb 3. 352(5):439-40. [QxMD MEDLINE Link].
Wutzler P, Knuf M, Liese J. Varicella: efficacy of two-dose vaccination in childhood. Dtsch Arztebl Int. 2008 Aug. 105(33):567-72. [QxMD MEDLINE Link]. [Full Text].
Bae S, Song YJ. Inhibition of varicella‑zoster virus replication by an ethanol extract of Lysimachia mauritiana. Mol Med Rep. 2017 Apr 7. [QxMD MEDLINE Link].
Dunkle LM, Arvin AM, Whitley RJ, et al. A controlled trial of acyclovir for chickenpox in normal children. N Engl J Med. 1991 Nov 28. 325(22):1539-44. [QxMD MEDLINE Link].
Vinzio S, Lioure B, Goichot B. Varicella in immunocompromised patients. Lancet. 2006 Dec 23. 368(9554):2208. [QxMD MEDLINE Link].
Safrin S, Berger TG, Gilson I, et al. Foscarnet therapy in five patients with AIDS and acyclovir-resistant varicella-zoster virus infection. Ann Intern Med. 1991 Jul 1. 115(1):19-21. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention (CDC). Updated recommendations for use of VariZIG – United States, 2013. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6228a4.htm?s_cid=mm6228a4_w. Accessed: July 23, 2013.
Asano Y, Nagai T, Miyata T, et al. Long-term protective immunity of recipients of the OKA strain of live varicella vaccine. Pediatrics. 1985 Apr. 75(4):667-71. [QxMD MEDLINE Link].
Leung J, Broder KR, Marin M. Severe varicella in persons vaccinated with varicella vaccine (breakthrough varicella): a systematic literature review. Expert Rev Vaccines. 2017 Apr. 16 (4):391-400. [QxMD MEDLINE Link].
[Guideline] Centers for Disease Control and Prevention. A new product (VariZIG) for postexposure prophylaxis of varicella available under an investigational new drug application expanded access protocol. MMWR Morb Mortal Wkly Rep. 2006 Mar 3. 55(8):209-10. [QxMD MEDLINE Link].
[Guideline] Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine. MMWR Morb Mortal Wkly Rep. 2008 Mar 14. 57(10):258-60. [QxMD MEDLINE Link].
[Guideline] Marin M, Broder KR, Temte JL, Snider DE, Seward JF. Use of combination measles, mumps, rubella, and varicella vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010 May 7. 59:1-12. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, 2009*. Ann Intern Med. 2009 Jan 6. 150(1):40-4. [QxMD MEDLINE Link].
[Guideline] Centers for Disease Control and Prevention. Recommended adult immunization schedule--United States, 2011. MMWR Morb Mortal Wkly Rep. 2011 Feb 4. 60(4):1-4. [QxMD MEDLINE Link]. [Full Text].
[Guideline] American Academy of Pediatrics Committee on Infectious Diseases. Prevention of varicella: recommendations for use of varicella vaccines in children, including a recommendation for a routine 2-dose varicella immunization schedule. Pediatrics. 2007 Jul. 120(1):221-31. Reaffirmed July 2010. [QxMD MEDLINE Link].
[Guideline] American Academy of Pediatrics Committee on Infectious Diseases. Recommended childhood and adolescent immunization schedules--United States, 2009. Pediatrics. 2009 Jan. 123(1):189-90. [QxMD MEDLINE Link].
[Guideline] Committee on Infectious Diseases; American Academy of Pediatrics. Policy statement--recommended childhood and adolescent immunization schedules--United States, 2011. Pediatrics. 2011 Feb. 127(2):387-8. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Committee on Infectious Diseases, American Academy of Pediatrics. Recommended childhood and adolescent immunization schedule--United States, 2014. Pediatrics. 2014 Feb. 133(2):357-63. [QxMD MEDLINE Link].
[Guideline] Barclay L. Guidelines revised on chicken pox in pregnancy. Medscape Medical News. Available at http://www.medscape.com/viewarticle/838532. Accessed: February 9, 2015.
Snoeck R, Andrei G, De Clercq E. Current pharmacological approaches to the therapy of varicella zoster virus infections: a guide to treatment. Drugs. 1999 Feb. 57(2):187-206. [QxMD MEDLINE Link].
Papadopoulos AJ, Schwartz RA, Janniger CK. Chickenpox. Cutis. 2000 Jun. 65(6):355-8. [QxMD MEDLINE Link].

Media Gallery

Dewdrop on rose petal characteristic vesicle of chickenpox. Reprinted with permission from Cutis 65: 355, 2000.
Vesicular eruption on the trunk demonstrating papules, vesicles, and crusts. Reprinted with permission from Cutis 65: 355, 2000.

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Author

Anthony J Papadopoulos, MD Private Practice

Anthony J Papadopoulos, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, Medical Society of New Jersey, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Coauthor(s)

Camila K Janniger, MD Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, Rutgers New Jersey Medical School

Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Van Perry, MD Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas School of Medicine at San Antonio

Van Perry, MD is a member of the following medical societies: American Academy of Dermatology and American Society for Laser Medicine and Surgery

Disclosure: Nothing to disclose.

Susan M Swetter, MD Director, Pigmented Lesion and Melanoma Program, Professor, Department of Dermatology, Stanford University Medical Center and Cancer Institute, Veterans Affairs Palo Alto Health Care System

Susan M Swetter, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society of Clinical Oncology, Eastern Cooperative Oncology Group, Pacific Dermatologic Association, Society for Investigative Dermatology, Society for Melanoma Research, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.