CASE PRESENTATION
VARICELLA
Presentant
Ratna Kurnianingsi
1102012228
dr. Ulynar M, Sp.A
Faculty of Medicine YARSI
Pediatric Department
Bhayangkara Tk. I R. Said Sukanto Hospital
• Patient’s
Identity
Name : Child AAMM
Birth Date : Januart 10st, 2016
Age : 1 years 11 months
Gender : Female
Address : Kober street RT 002/002,
Kramat Jati,East of Jakarta
Nationality : Indonesian
Religion : Islam
MR No. : 907789
Date of admission : December 9th, 2017
Date of examination : December 10th, 2017
• Parent’s
Identity
Father Mother
Name Mr. M Mrs. D
Age 28 years old 26 years old
Job Entrepreneur Housewife
Nationality Indonesian Indonesian
Religion Islam Islam
Education High school High school
Address Kober street RT 002/002, Balekambang,
Kramat Jati
Anamnesis
Chief Complaint
Rash that contains fluid filled The anamnesis was taken on
blisters on the skin since 1 day December 10th, 2017 using
before admission to the hospital. alloanamnesis method. It was
taken at room No.I Anggrek 2
Ward, Bhayangkara Tk. I Raden
Said Sukanto Hospital, Jakarta.
Additional Complaint
Fever, coughs and colds
History of Present Illness
3 days before 1 day before
admission admission
• Appears rash that
contains fluid filled
blisters on the
Colds and dry Cough Fever patient's skin.
fever is not too high and • The blisters appeared
temperature is settled. on the back then
The patient temperature spread to the waist,
37.7oC and patients have abdomen and face.
not taken any drugs to • The bliters feels itchy.
lowering the fever.
History of Past Illness
History of Past Illness History of Past Illness
Pharyngitis/Tonsilitis - Diarrhea -
Bronchitis - Thypoid -
Pneumonia -
Worms -
Morbilli -
Surgery -
Varicella -
Brain Concussion -
Diphteria -
Fracture -
Enteritis -
Drug Reaction -
Bacillary Dysentry -
Febril seizure -
Amoeba Dysentry -
Allergic History
The patient have no allergy to medicine
and food.
Mother’s Pregnancy History
• Antenatal Care
Mother checkups her pregnancy to midwife
monthly
• Pregnancy Illness
No history of problems and diseases during
pregnancy
• Drug Consumed
Mother get vitamins every antenatal care
Child’s Birth History
• Labor : Local clinic
• Birth attendants : Midwife
• Mode of delivery : Vaginal birth
• Gestation : 39 weeks
• Infant state : Healthy
• Birth weight : 3200 grams
• Body length : 48 cm
• According to the mother, the baby started to
cry, the baby’s skin is red, and no congenital
defects were reported.
Development History
Psychomotor development
Social Personality
Language
Smile: 2 months
Slant : 2 months
Reaching toys: 4
Speech initiation : 2 Screaming: 3 months
months
months Laughing : 3 months
Drinking from cup: 6
Prone position : 4 months Turn one’s head: 4
months
Sitting: 8 months months
Clapping hands: 4
Crawling : 7 months Papa/Mama: 7 months
months
Standing : 10 months
Walking : 14 months
Developmental in the normal limits and
appropriate according to the patient’s age.
Immunization History
Immunization Frequency Time
BCG 1 time 1 month old
Hepatitis B 3 times 0, 1, 6 months old
History of Eating
DPT 3 times 2, 4, 6 months old
- Breast milk : Until now
- Formula milk : SGM
Polio 4 times 0, 2, 4, 6 months
- Baby biscuit : Milna
old - Fruit and vegetables : Banana, papaya
Measles 1 times 9 months
Family Illness History
2 weeks before, the patient's
mother was sick of chickenpox
History of Sibling
• The patient is the first child of the family
• The patient has no sibling
• Born died : (-)
• Child dies : (-)
• Miscarriage : (-)
PHYSICAL EXAMINATION
December, 10th 2017
General Status
- General condition : Mildly ill
- Consciousness : Compos Mentis
- Pulse : 134 x/min
- Breathing rate : 24 x/min
- Temperature : 36,5 °C per axilla
Anthropometry Status
- Weight : 10 kg
- Height : 82 cm
Nutritional
Status
Based on NCHS (National Center for
Health Statistics) year 2000 :
• WFA (Weight for Age) : 10/11,8 x 100 %
= 85 % (good nutrition)
• HFA (Height for Age) : 82/85 x 100 % =
96 % (good nutrition)
• WFH (Weight for Height) : 10/11,4 x 100 %
= 88% (good noutrition)
Conclusion : the patient
has a good nutritional
status
Head to Toe Examination
• Head
Normocephal, hair (black, normal distribution, not easily
removed), no sign of trauma.
there is a vesicle s on the forehead
• Eyes
Scleral icterus -/-, pale conjunctiva -/-, lacrimation -/-, pupil
3mm/3mm, isocor, direct light response +/+, indirect light
response +/+.
• Ears
Normal shape, no wound, no bleeding, no secretion, no
cerumen.
• Nose
Normal shape, midline septum, secretion -/-. dry bloody secret
+/-
• Mouth
Lip : dry
Teeth : 16
Mucous : moist
Tongue : No dirty
Tonsils : T1/T1, no hyperemia
Pharinx : no hyperemia
• Neck
Lymph node enlargement (-), scrofuloderma (-).
• Thorax
Inspection : Symmetric when breathing, retraction (-), ictus
cordis is not visible
Palpation : Fremitus tactile +/+ symmetric, mass (-)
Percussion : Sonor on both lungs
Auscultation :
Cor : S1-S2 regular, murmur (-), gallop (-)
Pulmo : vesicular +/+, rhonchi -/-, wheezing -/-
• Abdomen
Inspection : Relax, spider nevi (-), mass (-)
there is some vesicles
Palpation : Abdominal mass (-), hepatomegaly (-),
splenomegaly (-)
Percussion : tympanic, shifting dullness (-)
Auscultation : Increased bowel sound, bruit (-)
• Vertebra
There is no scoliosis, kyphosis, lordosis, and any mass along the
vertebral line.
• Extremity
Warm, capillary refill time <2 second, edema -/-
Neurogical
Examination Motoric Examination
Meningeal Sign Pathologic Reflex
Upper extremities
-Hoffman - / -
Nuchal rigidity (-) -Trommer - / -
Kernig sign Lower extremities
(-)
-Babinsky - / -
Lasegue sign (-) -Chaddock - / -
-Oppenheim - / -
Brudzinski I (-) -Gordon - / -
Brudzinski II (-) -Schaeffer - / -
Power
-Hand 5 5 5 5 / 5 5 5 5
-Feet 5 5 5 5 / 5 5 5 5
Tonus
-Hand Normotonus/ Normotonus
-Feet Normotonus / Normotonus
Trophy
-Hand Normotrophy / Normotrophy
-Feet Normotrophy / Normotrophy
Autonomic
Examination
Defecation Normal (frequency 1 times
daily)
Urination Normal (4-5 times daily)
Sweating Normal
Laboratory
Investigation
December, 9th 2017
Results Normal Value
Hemoglobin 10,2 12 – 14 g/dl
White blood cells 10.400 5.000 – 10.000 u/l
Hematocrit 31 37 – 43 %
Platelet count 357.000 150.000 –400.000 /ul
Working Diagnosis
1. Varicella
2. Normal Growth Status
3. Good Nutritional Status
Management
IVFD RL 1000cc/24hours
Acyclovir 3x20 mg
Paracetamol syr 1 x 1 cth
Cetirizin 1 x 1 ampul
Ambroxol syr 3 x 2,5 ml
Cefotaxime 2 x 500 mg IV
Salicyl powder
PROGNOSIS
Quo ad vitam
dubia ad bonam
Quo ad fungsionam
dubia ad bonam
Quo ad sanactionam
Dubia ad bonam
Cough
S Colds
Fluid filled spots on the skin, itchy
Consciousness : Compos Mentis
General condition: Midly ill
Temperature :37,1 °C
Pulse :121 x/min
Respiratory rate : 24 x/min FOLLOW UP
Head : Normocephal, On the forehead there are some vesicles December 10th 2017, 2nd day of
Eyes : Pale conjungtiva (-), icteric sklera (-), sunken eyes (-), hospitalization, 3rd day of illness
Mouth : Dry lips, moist mucous, tonsils T1/T1, hyperemia pharynx (-)
Pulmonary: Vesicular +/+, rhonchi -/-, wheezing -/-, retraction +
Cardio : S1 S2 regullar, murmur (-), gallop (-)
Abdomen : Distention (-), bowel sound (+) normal,shifting dullness (-), there is
some vesicles
Extremity: Warm, CRT <2 seconds
Varicella
A
Normal nutritional and development status
- IVFD RL 1000cc/24hours
P - Acyclovir 3 x 20 mg
- Ambroxol syr 3 x 2,5 ml
Cough
S Colds
Fluid filled spots on the skin, itchy
Consciousness : Compos Mentis
General condition: Midly ill
Temperature :36,8 °C
Pulse :114 x/min
Respiratory rate : 23 x/min
Head : Normocephal, On the forehead there are some vesicles
Eyes : Pale conjungtiva (-), icteric sklera (-), sunken eyes (-), FOLLOW UP
Mouth : Dry lips, moist mucous, tonsils T1/T1, hyperemia pharynx (-) December 11th 2017, 3rd day of
Pulmonary: Vesicular +/+, rhonchi -/-, wheezing -/-, retraction +
hospitalization, 4th day of illness
Cardio : S1 S2 regullar, murmur (-), gallop (-)
Abdomen : Distention (-), bowel sound (+) normal, shifting dullness (-), there is some
vesicles
Extremity: Warm, CRT <2 seconds
Varicella
A
Normal nutritional and development status
- IVFD RL 1000cc/24hours
- Acyclovir 3 x 20 mg
- Ambroxol syr 3 x 2,5 ml
P - Paracetamol syr 1 x 5 ml
- Cetirizin 1 x 1 ampul
- Cefotaxime 2 x 500 mg
- Salicyl powder
Cough
S Colds
Fluid filled spots on the skin, itchy
Consciousness : Compos Mentis
General condition: Midly ill
Temperature :36,8 °C
Pulse :114 x/min
Respiratory rate : 23 x/min
Head : Normocephal, On the forehead there are some vesicles
Eyes : Pale conjungtiva (-), icteric sklera (-), sunken eyes (-), FOLLOW UP
Mouth : Dry lips, moist mucous, tonsils T1/T1, hyperemia pharynx (-) December 12th 2017, 3rd day of
Pulmonary: Vesicular +/+, rhonchi -/-, wheezing -/-, retraction +
hospitalization, 4th day of illness
Cardio : S1 S2 regullar, murmur (-), gallop (-)
Abdomen : Distention (-), bowel sound (+) normal, shifting dullness (-), there is some
vesicles
Extremity: Warm, CRT <2 seconds
Varicella
A
Normal nutritional and development status
- IVFD RL 1000cc/24hours
- Acyclovir 3 x 20 mg
- Ambroxol syr 3 x 2,5 ml
P - Paracetamol syr 1 x 5 ml
- Cetirizin 1 x 1 ampul
- Cefotaxime 2 x 500 mg
- Salicyl powder
Literature
Review and
Discussion
Definition
Varicella (Chickenpox) is a primary
acute infection by Varicella Zoster
Virus that attacks the skin and
mucosa
Etiology
Varicella Zooster Virus (VZV)
• Diameter of approximately 150 - 200
nm.
• The virus core is called an icosahedral-
shaped capsid,
• Core: protein and double-chain DNA
• Tegument Protein -virus replication.
- Infectious nature
• Replication (4-10 hours) expression
of viral proteins and formation of
multinucleated giant cells
Patogenesis
CLINICAL MANIFESTATIONS
Eruption Stadium
Prodromal Stadium
• 1-2 days -> skin rash "dew drops on rose
petals" (face, neck, head, body and
extremities) accompanied by itching
10-21 days 1-3 hr fever, chills, • Dispersion from the center to the periphery
headache, anorexia and malaise macules, papules, vesicles, pustules,
and crusts
• Cloudy vesicle liquid due to inflammatory
cell sebukan (PMN) Pustul Crust
• Crusta release 1-3 weeks depending on the
skin disorder.
• Skin lesions are limited in epidermal tissue
-> 7-10 days of healing
Varicella in pregnancy
• Varicella 21 days before delivery 25% of
children -> congenital varicella in 0-5 days, mild,
rarely death
• Varicella 4-5 days before delivery neonate
congenital varicella 5-19 days, severe varicella
and death 25-30%
• Child of the varicella mother during pregnancy, or
varicella infant during the first month herpes
zoster < 2 years >>
Diagnosa
• Can be enforced clinically distinctive skin lesion
description
• Appears after a short & light prodromal period
• Changes in rapid lesions of macules, vesicles, pustules to
crusts
• The presence of all levels of skin lesions at the same time
in the same area
• There are oral mucosal lesions
• Generally Laboratory examination is not needed anymore
Complications
Secondary infection with bacteria caused
by staphylococci: impetigo, cellulitis,
fascitis, erysipelas, furuncle, abscess,
scarlet fever, or sepsis
Reye syndrome -> lethargy, nausea, persistent
vomiting, confusion and sensory changes.
Varicella Pneumonia ->
immunocompromised patients, and
pregnancy -> high heat, cough, shortness
of breath, takipneu, wet rhythm, cyanosis,
and hemoptoe a few days after the rash.
X-ray radio-opaque radiographs on both
lungs
Treatment
Non-Medical Management:
• Isolation to prevent transmission
• When the fever is high, compress with warm water
• Try not to break the vesicles -> use powder
• Do not scratch the vesicles
• Nails should not be left long
• If you want to dry the body, just put a towel on the skin, Do not be rubbed
Medical Management:
• Symptomatic - Antipyretics
• Antihistamines
• Shake Powder (lotio calamine) -> to reduce itching
• Acyclovir:
- Neonates: 500 mg / m2 iv every 8 hours, for 10 days
- Child (2-12 years) 20 mg / kg (max 800 mg) 4-5 times daily
for 5-10 days.
• Topical antibiotics (reducing infected rash)
Prevention
Vaccinations
• Protection of varicella up to 71 - 100%
• More effective in children after> 1 year.
• <13 years -> single dose
• > 13 Years -> Two doses are given with
intervals of 4 - 8 weeks.
Varicella Zooster Immunoglobin (VZIG)
• Prophylaxis after exposure to the virus, and
especially to people at high risk
• Dose 125 IU / 10 kgBB.
• 125 IU is a minimal dose, while the maximum dose
is 625 IU and administered intramuscularly
REFERENCES
• Centers for Disease Control and Prevention (CDC): Evolution of varicella surveillance–selected states, 2000-2010, MMWR Morb
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1997–2005, J Infect Dis 197:S127– S131, 2008.
• Djuanda A, Kosasih A, Wiryadi BE, dkk. 2013. Ilmu Penyakit Kulit dan Kelamin. Jakarta : Fakultas Kedokteran Universitas
Indonesia.
• Harris D, Redhead J: Should acyclovir be prescribed for immunocompetent children presenting with chickenpox? Arch Dis Child
90:648–650, 2005.
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Arch Dermatol 140:1268–1272, 2004.
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2010.
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• Schachner, Lawrence. Pediatric Dermatology Third Edition. Mosby. 2003
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• Soedarmo SSP, Gama H, Hadinegoro SRH, dkk. 2008. Buku Ajar lnfeksi & Pediatri Tropis. Edisi Kedua. Jakarta : Ikatan Dokter
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• Son M, Shapiro ED, LaRussa P, et al: Effectiveness of varicella vaccine in children infected with HIV, J Infect Dis 201(12):1806–
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