Clinical Exposure

Case Report by Oki Yonatan Oentiono 07120070074

12 February 2009
1. Patient Information
Sex : Male
!e : " years # mont$s
%ei!$t : 1" &!
'ob : (
Social : ( E)ucation : (
(%or& : (
())ress : Cariyu
2. *ata +at$erin!
C$ief complaint
,e)- itc$y ras$ on t$e ab)omen- trun&- bac& an) face.
.t$er complaint
Some small- li/ui)(0lle) blisters t$at brea& open an) crust
o1er- loss of appetite- fe1er- no eyes )efect- no )i22iness- no bloo)
in t$e feces- no cou!$- no $ea)ac$e
Past $istory
3ast 4ee& $e !ot cou!$ an) 5u- but alrea)y $eale) yester)ay
4it$ me)icine from pus&esmas.
Family $istory
6$e patient7s brot$er )e1elops c$ic&en pox last 2 4ee&s-
alrea)y $eale) by pus&esmas7s me)icine fe4 )ays a!o.
.t$er..
8e al4ays play 4it$ $is brot$er in t$e $ouse
P$ysical Examination
8eart rate : 90 9:min-
;loo) pressure : 100:#0-
,espiratory rate : 20 9:min
Inspection : ;lister- 4$ite 1esicle 4it$ re) rin! base
sprea)in! a lot in
trun&al- ab)omen an) face- some in $an)
an) foot
Palpation : 3i1er an) spleen are normal- no pain in
ab)omen
Percussion : <o mass- no or!ans enlar!ement- no pain
uscultation : 3i1er an) spleen are normal- no bruit
soun)- normal intestine soun)-
timpani soun) on epi!astric
=. In1esti!ation nee)e)
Expecte) result
62anc& smear of 1esicular 5ui) )emonstrates multinucleate)
!iant cells an) epit$elial cells 4it$ eosinop$ilic intranuclear
inclusion bo)ies
Isolation of t$e >?> 1irus t$rou!$ culture of 1esicular 5ui) or
t$rou!$ )irect immuno5uorescence stu)y
Serolo!ic e1i)ence of immunity @nati1e I!+ formationA can be
ac$ie1e) t$rou!$ a number of )iBerent assays @e!- en2yme
immunoassay CEID- in)irect 5uorescent antibo)y CIFD- complement
0xation- 5uorescent antibo)y to membrane assay CFMD- latex
a!!lutination testA. 6$e latex a!!lutination test for )eterminin!
exposure an) immunity to >?>.
8istolo!ic Fin)in!s
3eu&ocytoclastic 1asculitis an) $emorr$a!e
". Summary
;oy- " years # mont$s- 1" &! 4it$ re)- itc$y ras$ on t$e
ab)omen- trun&- bac& an) face. 8eart rate 90 9:min- ;P 100:#0- ,,
20 9:min. Inspection 0n) ;lister- 4$ite 1esicle 4it$ re) rin! base
sprea)in! a lot in trun&al- ab)omen an) face- some in $an) an) foot.
Palpation an) percussion 0n)in! normal. uscultation 0n)in!s li1er
an) spleen are normal- no bruit soun)- normal intestine soun)-
timpani soun) on epi!astric.
Some small- li/ui)(0lle) blisters t$at brea& open an) crust
o1er- loss of appetite- fe1er- no eyes )efect- no )i22iness- no bloo)
in t$e feces- - no $ea)ac$e. 3ast 4ee& $e !ot cou!$ an) 5u- but
alrea)y $eale) yester)ay 4it$ me)icine from pus&esmas. 6$e
patient7s brot$er )e1elops c$ic&en pox last 2 4ee&s- alrea)y $eale)
by pus&esmas7s me)icine fe4 )ays a!o. 8e al4ays play 4it$ $is
brot$er in t$e $ouse.
E. *ia!nosis
%or&in! )ia!nosis
C$ic&enpox
*iBerential )ia!nosis
Bullous Pemphigoid, Herpes Simplex, Dermatitis Herpetiformis,
Impetigo, Drug Eruptions, Insect Bites, Erythema Multiforme, and Syphilis.
F. nalysis
*ia!nostic reasonin! an) )iBerential )ia!nosis
C$ic&enpox is li&ely become t$e )ia!nosis. C$ic&enpox cause)
by 1aricella(2oster 1irus @>?>A conta!ious perio) continues until all
blisters $a1e forme) scabs- 4$ic$ may ta&e E to 10 )ays. It ta&es
from 10 to 21 )ays after contact 4it$ an infecte) person for
someone to )e1elop c$ic&enpox. ;ullous Pemp$i!oi)- *ermatitis
8erpetiformis an) 8erpes Simplex nee) speci0c lab results to
)ia!nose). *ru! eruption is not li&ely- because $e )i)n7t ta&e any
)ru! course. Impeti!o also exclu)e) because t$e 1esicle s$oul) be
0lle) 4it$ pus:exu)ates @yello4 colorA. Insect bites usually topical
an) not sprea)in! all o1er t$e bo)y. Eryt$ema Multiforme nee)s C;C
lab 0n)in!s an) $istolo!ically t$e 1esicle s$oul) be 0lle) 4it$
neutrop$il an) eusinop$il. Syp$ilis unco1er topical c$ancre lesion on
t$e infection site 4$ic$ is ulcer@t$is patient lesion clearly not ulcerA.
#. Su!!este) 6reatment
Healthy children
Primary varicella infection in the healthy child is a rather benign disease that
requires symptomatic therapy only. Pruritus can be treated with calamine lotion or
pramoxine gel, powdered oatmeal baths, or oral antihistamines.
The nucleoside analogue acyclovir given orally (20 mg!g P" qid for # d$ to
children, though shown to decrease the duration and the symptoms of primary varicella
infection when administered within 2% hours of onset of symptoms, is not commonly
prescribed in healthy children.
&hildren with defects in cell'mediated immunity, chronic atopic dermatitis or
asthma, iatrogenic immunosuppression or long'term systemic steroid use, splenic
dysfunction, or nephrotic syndrome should be treated because of the high ris! of
varicella'related complications.
G. Patient ,eaction
Feelin!s : 3et$ar!y
Insi!$t : ccor)in! to $is mot$er- $er son7s )isease is a
common one an) treatable
Fear : S$e fears t$at t$e blister 4ill lea1e a mar&.
Expectations : S$e $ope $er son reco1er as fast as possible
9. *isease ,e1ie4
C$ic&enpox
C$ic&enpox or c$ic&en pox is a $i!$ly conta!ious illness cause)
by primary infection 4it$ 1aricella 2oster 1irus @>?>A. It !enerally
be!ins 4it$ a 1esicular s&in ras$ appearin! in t4o or t$ree 4a1es-
mainly on t$e bo)y an) $ea) rat$er t$an t$e $an)s an) becomin!
itc$y ra4 poc&mar&s- small open sores 4$ic$ $eal mostly 4it$out
scarrin!.
C$ic&enpox $as an incubation perio) of 10 to 21 )ays- an) is
sprea) easily t$rou!$ cou!$s or snee2es of ill in)i1i)uals- or t$rou!$
)irect contact 4it$ secretions from t$e ras$. Follo4in! primary
infection t$ere is usually lifelon! protecti1e immunity from furt$er
episo)es of c$ic&enpox.
C$ic&enpox is rarely fatal- alt$ou!$ it is !enerally more se1ere
in a)ults t$an in c$il)ren. Pre!nant 4omen an) t$ose 4it$ a
suppresse) immune system are at $i!$est ris& of serious
complications. 6$e most common late complication of c$ic&en pox is
s$in!les- cause) by reacti1ation of t$e 1aricella 2oster 1irus )eca)es
after t$e initial episo)e of c$ic&enpox.
Pat$op$ysiolo!y
C$ic&enpox is usually ac/uire) by t$e in$alation of airborne
respiratory )roplets from an infecte) $ost. 6$e $i!$ly conta!ious
nature of >?> explains t$e epi)emics of c$ic&enpox t$at sprea)
t$rou!$ sc$ools as one c$il) 4$o is infecte) /uic&ly sprea)s t$e
1irus to many classmates. 8i!$ 1iral titers are foun) in t$e
c$aracteristic 1esicles of c$ic&enpoxH t$us- 1iral transmission may
also occur t$rou!$ )irect contact 4it$ t$ese 1esicles- alt$ou!$ t$e
ris& is lo4er.
fter initial in$alation of contaminate) respiratory )roplets-
t$e 1irus infects t$e conIuncti1ae or t$e mucosae of t$e upper
respiratory tract. >iral proliferation occurs in re!ional lymp$ no)es
of t$e upper respiratory tract 2(" )ays after initial infection an) is
follo4e) by primary 1iremia on postinfection )ays "(F. secon)
roun) of 1iral replication occurs in t$e bo)yJs internal or!ans- most
notably t$e li1er an) t$e spleen- follo4e) by a secon)ary 1iremia 1"(
1F )ays postinfection. 6$is secon)ary 1iremia is c$aracteri2e) by
)iBuse 1iral in1asion of capillary en)ot$elial cells an) t$e epi)ermis.
>?> infection of cells of t$e malpi!$ian layer pro)uces bot$
intercellular e)ema an) intracellular e)ema- resultin! in t$e
c$aracteristic 1esicle.
Exposure to >?> in a $ealt$y c$il) initiates t$e pro)uction of
$ost immuno!lobulin + @I!+A- immuno!lobulin M @I!MA- an)
immuno!lobulin @I!A antibo)iesH I!+ antibo)ies persist for life
an) confer immunity. Cell(me)iate) immune responses are also
important in limitin! t$e scope an) t$e )uration of primary 1aricella
infection. fter primary infection- >?> is $ypot$esi2e) to sprea)
from mucosal an) epi)ermal lesions to local sensory ner1es. >?>
t$en remains latent in t$e )orsal !an!lion cells of t$e sensory
ner1es. ,eacti1ation of >?> results in t$e clinically )istinct
syn)rome of $erpes 2oster @s$in!lesA.
International Epi)emiolo!y
Countries 4it$ tropical an) semitropical climates $a1e a $i!$er
inci)ence of a)ult c$ic&enpox compare) 4it$ countries 4it$ a
temperate climate @e!- Knite) States- EuropeA.
Mortality:Morbi)ity
C$ic&enpox aBectin! a $ealt$y c$il) is usually a self(limite)
)isease. Secon)ary bacterial infection of s&in lesions- manifestin! as
impeti!o- cellulitis- or erysipelas- is t$e most common complication
in t$is population. Stap$ylococci an) streptococci are t$e most
commonly implicate) bacterial pat$o!ens. ;acterial superinfection
may pre)ispose to scarrin!. 3ocali2e) bacterial superinfection may
rarely result in septicemia- culminatin! in a secon)ary bacterial
pneumonia- otitis me)ia- or necroti2in! fasciitis.
Con!enital infection 4it$ t$e >?> 1irus is also a concern.
Maternal c$ic&enpox )urin! pre!nancy may pro)uce latency of t$e
>?> 1irus in t$e )orsal root !an!lia of t$e fetus. 6$ese c$il)ren may
remain asymptomatic- or t$ey may )e1elop $erpes 2oster at a youn!
a!e 4it$out pre1ious $istory of primary c$ic&enpox infection.
Primary maternal c$ic&enpox infection )urin! t$e 0rst 20 4ee&s of
!estation may also rarely pro)uce t$e con!enital 1aricella syn)rome-
4$ic$ is c$aracteri2e) by limb $ypoplasia- muscular atrop$y- s&in
scarrin!- cortical atrop$y- microcep$aly- cataract formation- an)
ru)imentary )i!its.
Causes
C$ic&enpox is usually ac/uire) by t$e in$alation of airborne
respiratory )roplets from a >?>(infecte) $ost. 8i!$ 1iral titers are
foun) in t$e c$aracteristic 1esicles of c$ic&enpoxH t$us- 1iral
transmission may also occur t$rou!$ )irect contact 4it$ t$ese
1esicles.