The child is 4 years old, attends kindergarten. The onset is acute, with an increase in body temperature to 38.0 C, and the appearance of a rash. On examination: general condition of moderate severity. The body temperature is 38.0 C. the skin of the usual color, throughout the body, on the upper and lower extremities, as well as on the scalp, there are spotty-papular, vesicular elements and single crusts. The oropharynx is calm. There is vesicular breathing in the lungs, there are no wheezing. Respiration rate is 18 times per minute. The heart tones are clear, rhythmic. Heart rate-108 times per minute. The tongue is moist, clean. Abdomen is soft, painless. The liver and spleen are not enlarged. The stool is decorated. Urination is free, painless. 1. Поставьте предварительный диагноз/Алдын-ала диагноз қойыныз/ Put the preliminary diagnosis 2. Проведите дифференциальную диагностику/Аажырату диагностикасын жааңыз/ Маке differential diagnostics 3. Назначьте обследование и напишите ожидаемые результаты Тексеруді тағайындаңыз және күтілетін нәтижелерді жазыныз/ Schedule an examination and write down the expected results Ваша лечебная тактика/Сіздің емдік тактиканыз/ Your treatment tactics with dose 5. 4. Профилактические мероприятия при данном заболевании/Бұл аурудың алдын алу шаралары/ Preventive measures for this disease #440 Soha
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Case #440 — Clinical Analysis
Patient: 4-year-old child, kindergarten attendee. Acute onset, fever 38.0°C, generalized polymorphic rash (macular-papular → vesicular → crusts) on trunk, extremities, and scalp.
1. Preliminary Diagnosis
Varicella (Chickenpox) — mild form, typical course.
Rationale:
- Age group and kindergarten contact (classic epidemiologic setting)
- Acute onset with low-grade fever (38°C)
- Polymorphic rash (simultaneous presence of macules, papules, vesicles, and crusts = "starry sky" pattern) — pathognomonic for varicella
- Scalp involvement — highly characteristic; few exanthems affect the scalp
- Distribution: generalized (trunk, upper and lower extremities, scalp)
- No oropharyngeal involvement, no respiratory compromise
"Varicella begins with a brief prodrome of 1 to 2 days of fever...followed by the characteristic exanthem. The rash begins on the head and trunk and spreads centrifugally to the extremities. The hallmark of varicella is the simultaneous presence of lesions at all stages of development — macules, papules, vesicles, pustules, and crusts — in the same area of skin." — Fitzpatrick's Dermatology, p. 3065
2. Differential Diagnosis
| Condition | Key Distinguishing Features |
|---|---|
| Herpes simplex disseminatus | Grouped vesicles on erythematous base; dermatomal/localized distribution; no scalp lesions typically |
| Impetigo (bullous) | Honey-colored crusts, no true vesicular stage, no fever, Staphylococcal etiology, usually localized |
| Hand-foot-mouth disease (Coxsackievirus A16) | Vesicles limited to palms, soles, oral mucosa; no scalp involvement |
| Insect bite reactions (papular urticaria) | No fever, no progression to vesicles, no scalp, often grouped/linear |
| Molluscum contagiosum | Umbilicated pearly papules, no vesicles, no fever |
| Smallpox (variola) | Lesions all at same stage simultaneously (unlike varicella); centrifugal distribution; currently eradicated; prodrome more severe |
| Drug rash / morbilliform eruption | No vesicles, linked to medication use, no progression to crusts |
| Rickettsialpox | Eschar at bite site, fever; vesicular; rare |
Key varicella features that clinch the diagnosis:
- Pleomorphism (all stages present simultaneously)
- Scalp involvement
- Pruritic vesicles on erythematous base ("dewdrop on rose petal")
- Mild fever, kindergarten exposure
3. Examination and Expected Results
Clinical Laboratory
| Test | Expected Result |
|---|---|
| CBC (Complete Blood Count) | Leukopenia or normal WBC; relative lymphocytosis; normal or mildly elevated ESR |
| Urinalysis | Within normal limits |
Specific/Virological Diagnostics (in typical uncomplicated childhood varicella, usually not required — diagnosis is clinical)
| Test | Expected Result |
|---|---|
| PCR (vesicle fluid/lesion scraping) | VZV DNA detected — gold standard; high sensitivity and specificity |
| Tzanck smear (scraping from vesicle base, Giemsa or H&E stain) | Multinucleated giant cells with eosinophilic intranuclear inclusion bodies (present in both VZV and HSV — not specific but confirms herpetic origin) |
| VZV IgM serology | Positive (rises early in infection) |
| VZV IgG | Absent initially (seroconversion over 2–4 weeks confirms primary infection) |
| Viral culture | VZV isolation (low sensitivity ~30–60%; rarely used) |
"The best diagnostic test for detection of VZV is polymerase chain reaction (PCR) because of its very high sensitivity and specificity, ready availability, and relatively quick (1 day or less) turnaround time." — Fitzpatrick's Dermatology, p. 3076
4. Treatment Tactics with Doses
Symptomatic (First-line for immunocompetent children — mild form):
| Intervention | Dose / Instructions |
|---|---|
| Antipyretics | Paracetamol (acetaminophen) 10–15 mg/kg/dose every 4–6 h as needed. Never use aspirin (risk of Reye syndrome) |
| Antihistamines (oral) — for pruritus | Chloropyramine (Suprastin) or cetirizine — age-appropriate dose to reduce scratching |
| Topical / local relief | Calamine lotion or zinc oxide lotion applied to lesions; tepid baths with colloidal oatmeal or sodium bicarbonate (3 cups per tub) |
| Skin hygiene | Keep fingernails short and clean; avoid scratching (prevents secondary bacterial infection) |
| Secondary bacterial infection | If cellulitis develops: systemic antibiotics active against S. aureus and group A streptococcus (e.g., amoxicillin-clavulanate or cephalexin) |
Antiviral Therapy (if initiated — should begin within 24 hours of rash onset for benefit):
For an immunocompetent child aged 2–18 years:
| Drug | Dose |
|---|---|
| Acyclovir (oral) | 20 mg/kg per dose, 4 times daily × 5 days (max 800 mg/dose, max 3200 mg/day) |
| Valacyclovir (oral) | 20 mg/kg per dose, every 8 h × 5 days (max 1 g/dose, max 3 g/day) |
"Treatment with oral acyclovir (20 mg/kg 4 times per day for 5 days) initiated within 24 hours of rash onset modestly reduced the maximum number of lesions, the time to cessation of new lesion formation, and the duration of the rash, fever, and constitutional symptoms." — Fitzpatrick's Dermatology, p. 3081
Note: In otherwise healthy young children with mild varicella, antiviral therapy is optional (symptomatic treatment alone is acceptable per guidelines). Antivirals are strongly indicated for adolescents, adults, immunocompromised patients, and severe/complicated cases.
Hospital Admission Criteria (not required in this case):
- Complications: pneumonia, encephalitis, secondary bacterial infection, hemorrhagic varicella
- Immunocompromised state
5. Preventive Measures
Isolation:
- The child should be isolated at home (excluded from kindergarten) from the first day of illness until all lesions are fully crusted (typically 5–7 days after rash onset)
- Infectious period: 1–2 days before rash to 4–5 days after last crop of vesicles has crusted
- Transmission route: airborne droplets and direct contact (not via crusts — crusts are non-infectious)
Contact Management:
- Notify the kindergarten; identify susceptible contacts
- Susceptible contacts (unvaccinated, no prior infection) should be monitored for 21 days (maximum incubation period)
- Post-exposure prophylaxis within 3 days (72–96 hours) of exposure:
- Varicella vaccine (live attenuated, Oka strain) — reduces risk by ~2/3
- Varicella-zoster immune globulin (VZIG/VariZIG) — for high-risk susceptible contacts (immunocompromised, pregnant, neonates)
Active Immunization (primary prevention):
- 2-dose varicella vaccine schedule:
- 1st dose: 12–15 months
- 2nd dose: 4–6 years
- Vaccine protects 70–90% against any varicella and >95% against severe disease
- Vaccine is contraindicated in immunocompromised individuals and pregnant women
"A single dose...protects 70 to 90% of recipients against any disease and more than 95% against severe disease, but a two-dose schedule is recommended." — Goldman-Cecil Medicine, p. 179
"Postexposure vaccination within 3 days of exposure can reduce the likelihood of symptomatic infection by about two-thirds." — Goldman-Cecil Medicine, p. 179
General Measures:
- Hand hygiene education
- Disinfection of toys and commonly touched surfaces in the kindergarten
- Air ventilation of rooms
- Reporting to local sanitary/epidemiological authority (varicella is a notifiable disease in many countries)
Sources:
- Fitzpatrick's Dermatology, 9th Ed. — Chapter 165: Varicella-Zoster Virus Infections
- Goldman-Cecil Medicine, International Edition — Chapter 346: Varicella-Zoster Virus (Chickenpox, Shingles)
Short
Case #440 — Varicella (Chickenpox), Mild Form
1. Diagnosis
Varicella (chickenpox), typical mild form.
Basis: acute onset, fever 38°C, polymorphic rash (macules → papules → vesicles → crusts simultaneously), scalp involvement, kindergarten contact.
2. Differential Diagnosis
| Disease | Key difference |
|---|---|
| Hand-foot-mouth disease | Vesicles only on palms, soles, oral mucosa; no scalp |
| Impetigo | Honey crusts, localized, no fever |
| Insect bites | No fever, no vesicles, no scalp |
| Smallpox | All lesions same stage; eradicated |
3. Investigations & Expected Results
| Test | Expected |
|---|---|
| CBC | Leukopenia, lymphocytosis |
| PCR (vesicle fluid) | VZV DNA positive |
| Tzanck smear | Multinucleated giant cells |
| VZV IgM | Positive |
4. Treatment
| Drug | Dose |
|---|---|
| Paracetamol (fever/pain) | 10–15 mg/kg/dose q4–6h — no aspirin (Reye syndrome) |
| Cetirizine (antihistamine) | 2.5 mg/day (<6 yr) for pruritus |
| Calamine lotion | Topical — to lesions |
| Acyclovir (oral, if within 24h) | 20 mg/kg × 4 times/day × 5 days (max 800 mg/dose) |
5. Prevention
- Isolate at home until all lesions are crusted (~5–7 days)
- Notify kindergarten; monitor contacts for 21 days
- Post-exposure vaccine within 72h of contact
- Vaccination schedule: 2 doses (12–15 months + 4–6 years)
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