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 :: Introduction
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ORIGINAL ARTICLE
Year : 2013  |  Volume : 59  |  Issue : 2  |  Page : 93-97

An observational study of complications in chickenpox with special reference to unusual complications in an apex infectious disease hospital, Kolkata, India


1 Department of Medicine, ID and BG Hospital, Kolkata, West Bengal, India
2 BP Poddar Hospital and Research Centre, Kolkata, West Bengal, India

Date of Submission05-Jul-2012
Date of Decision26-Nov-2012
Date of Acceptance01-Feb-2013
Date of Web Publication21-Jun-2013

Correspondence Address:
A K Kole
Department of Medicine, ID and BG Hospital, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.113811

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 :: Abstract 

Background: Chickenpox can cause serious complications and even death in persons without any risk factors. Aims: To observe the different complications with special reference to unusual complications of chickenpox and their outcomes. Materials and Methods: The present study was a prospective observational study where 300 patients suffering from chickenpox were evaluated with special reference to unusual complications and outcomes. Results: The usual complications of chickenpox commonly observed were acute hepatitis in 30 (10%) and cerebellar ataxia in 22 patients (7.3%), whereas common unusual complications were acute pancreatitis in 45 (15%), hemorrhagic rash in 10 (3.3%), Guillain-Barrι syndrome in 4 (1.3%), disseminated intravascular coagulation in 4 (1.3%), necrotizing fasciitis in 4 (1.3%), and acute renal failure in 3 patients (1%). It had been observed that most of these unusual complications occurred in patients without any risk factor. A total of 18 patients (6%) died in this study and of them 12 patients (4%) died due to unusual complications. Conclusions: Compulsory childhood varicella vaccination including vaccination of risk groups and susceptible individuals are all essential to reduce the incidence of chickenpox, associated complications, and subsequent death.


Keywords: Chickenpox, outcomes, unusual complications


How to cite this article:
Kole A K, Roy R, Kole D C. An observational study of complications in chickenpox with special reference to unusual complications in an apex infectious disease hospital, Kolkata, India. J Postgrad Med 2013;59:93-7

How to cite this URL:
Kole A K, Roy R, Kole D C. An observational study of complications in chickenpox with special reference to unusual complications in an apex infectious disease hospital, Kolkata, India. J Postgrad Med [serial online] 2013 [cited 2019 Nov 17];59:93-7. Available from: http://www.jpgmonline.com/text.asp?2013/59/2/93/113811



 :: Introduction Top


Chickenpox is highly infectious, self-limiting disease affecting all age groups and can cause serious life-threatening complications particularly in elderly, pregnant women, smokers, or in immunocompromised patients. In recent years, it had been reported from United Kingdom that incidence of chickenpox in adult had doubled along with increased morbidity, hospitalization, and also mortality. [1],[2] This clustering of cases in adults is probably due to increasing varicella vaccination in children, decreased exposure to varicella-zoster virus, increased virus virulence, and the immigration of nonimmune adults from the tropics. [3] Whereas in the United States since the introduction of the routine varicella vaccination in 1995, hospitalizations, outpatient visits, and associated expenditures have declined dramatically among all age groups. [4] But in many developing countries like India, varicella vaccination is still not included in the National Immunization Programme; therefore, all age groups are equally susceptible, though recently many newer vaccines including varicella are being introduced in some states. [5] Besides, the usual complications of chickenpox, there may be development of several unusual complications and these may be Guillain-Barré syndrome, acute transverse myelitis, acute disseminated encephalomyelitis, optic neuritis, acute pancreatitis, acute acalculous cholecystitis, immune thrombocytopenia, disseminated intravascular coagulation (DIC), hemorrhagic rashes, hemorrhagic stroke (due to vasculopathy), Steven-Johnson syndrome, myocarditis/pericarditis, acute nephritic/nephrotic syndrome and rarely orchitis, synovitis, tympanic membrane rupture or cerebral thrombophlebitis. [6],[7]

The objectives of the present study were to observe the different unusual complications of chickenpox and their outcomes.


 :: Materials and Methods Top


This was a prospective observational study done in a tertiary care infectious disease hospital, Kolkata. Three hundred patients suffering from chickenpox were evaluated between March 2010 and February 2012. Detailed clinical examination was done and all patients were closely monitored for development of any complication even after the desquamation of rash. Approval from the Institutional Review Board was obtained prior to initiating the study and written informed consent was taken from all the patients. Routine blood tests including electrocardiography and chest X-ray were done in each case and serum amylase, lipase, cerebrospinal fluid analysis, arterial blood gas analysis, fibrin degradation product, CPK-MB, ultrasonography/CT scan of abdomen, MRI of brain/spinal cord, electromyography and nerve conduction velocity were done where indicated. Statistical analysis was done and point estimates were followed by 95% confidence interval in parentheses.


 :: Results Top


The mean age was 35.12 years (±16.23) with the male to female ratio 1.5:1 and 42 patients had comorbidities [Table 1]. Ten patients were neonate who developed chickenpox within the first week of birth, and all recovered without any major complication [Figure 1]. The usual complications observed were acute hepatitis in 30 cases (10%) (6.61, 13.39) - most of them were anicteric and all recovered without hepatic failure; acute cerebellar ataxia in 22 cases (7.3%) (4.36, 10.24) - all recovered within a period of 4-6 weeks; localized skin infection [Figure 2] in 18 cases (6%) (3.31, 8.69); meningoencephalitis in 15 cases (5%) (2.53, 7.47) -2 of them succumbed and varicella pneumonia [Figure 3] in 12 cases (4%) (1.78, 6.22) - all were elderly with history of chronic obstructive airway diseases and 4 of them died [Table 2]. The most common unusual complication observed was acute pancreatitis seen in 45 cases (15%) (10.96, 19.04), 10 of them had severe form of the disease and 3 patients died due to multiorgan dysfunction syndrome [Table 3]. The next common unusual complication was hemorrhagic rash [Figure 4] - observed in 10 patients (3.3%) (1.28, 5.32) and all were immunocompetent with normal thrombocyte count [Table 2]. Guillain-Barré syndrome developed in 4 patients (1.3%) (0.02, 2.58) - all were young adults and immunocompetent and 2 of them died. Necrotizing fasciitis [Figure 5] developed in 4 patients (1.3%) (0.02, 2.58) - all were malnourished children and treated with parenteral broad-spectrum antibiotics, but 2 of them required surgical intervention due to development of impending compartment syndrome. Four patients (1.3%) (0.02, 2.58) developed purpura due to acute thrombocytopenia and two of them required platelet transfusion. Four patients (1.3%) (0.02, 2.58) developed bleeding manifestations from multiple sites with normal platelet count, raised fibrin degradation product - acute disseminated intravascular coagulation (DIC) was diagnosed and 3 of them died as a result of uncontrolled bleeding. Acute renal failure developed in 3 patients (1%) (–0.13, 2.13) - all were middle aged without any previous history of hypertension or diabetes. Acute transverse myelitis was diagnosed in 2 patients (0.6%) (–0.27, 1.47) and one patient died due to rapid clinical deterioration. Two patients (0.6%) (–0.27, 1.47) developed acute disseminated encephalomyelitis [Figure 6] during the convalescence and one of them died. Two patients (0.6%) (–0.27, 1.47) developed severe anemia without any obvious bleeding - acute hemolytic anemia was diagnosed and required blood transfusion. Steven-Johnson syndrome developed in 2 patients (0.6%) (–0.27, 1.47) and one of them died due to severe sepsis [Figure 7]. One 7-year-old male boy (0.3%) (–0.32, 0.92) developed sudden onset altered sensorium on the seventh day of onset of rash and CT scan of brain revealed multiple intracranial bleed [Figure 8] with normal coagulation profile. One middle-aged male patient (0.3%) (–0.32, 0.92) developed sudden onset loss of vision in both eyes with normal ophthalmoscopy, MRI of brain, retinal angiogram, and visual evoked potential and regained vision after 1 week. In this case the possibility of transient cortical blindness was considered after ophthalmologic consultation. One 35-year-old female patient (0.3%) (–0.32, 0.92), non diabetic and normotensive, developed sudden onset palpitation, shortness of breath on the fifth day of onset of rash with ECG features suggestive of myocarditis and died due to ventricular arrhythmia. One young adult patient (0.3%) (–0.32, 0.92) developed acute chest pain with normal CPK-MB level and ECG features suggestive of acute pericarditis. One 8-year-old male child (0.3%) (–0.32, 0.92) developed nephrotic range proteinuria a week after the desquamation of rashes, and improved after supportive therapy. One 55-year-old female (0.3%) (–0.32, 0.92) developed right-sided facial palsy on fourth day of onset of rash along with loss of taste sensation on the right half of the tongue - Ramsay-Hunt syndrome was diagnosed [Figure 9].
Table 1: Age, sex, and comorbidities in chickenpox

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Table 2: Usual complications of chickenpox observed in this study

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Table 3: Unusual complications of chickenpox observed in the present study

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Figure 1: A case of neonatal chickenpox

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Figure 2: Chickenpox in a diabetic with extensive rashes with superadded secondary bacterial infection

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Figure 3: Varicella pneumonia in a 14 year old boy

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Figure 4: Hemorrhagic rash of chickenpox

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Figure 5: Necrotizing fasciitis in a case of chickenpox

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Figure 6: Post chickenpox demyelination in a 35-year-old male

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Figure 7: A case of Steven-Johnson syndrome following chickenpox

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Figure 8: Hemorrhagic stroke in a 7 year old male child with chickenpox

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Figure 9: Facial palsy in a case of chickenpox

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 :: Discussion Top


In the present study, it had been observed that both the usual and unusual complications of chickenpox occurred with almost equal incidence (32% and 29%, respectively), though the unusual complications were responsible for higher mortality (just double). The most common usual complication observed was acute hepatitis and all recovered, though fatal outcome as a result of acute hepatic failure were reported. [8] Acute cerebellar ataxia was the next common usual complication, observed mainly in elderly patients and all recovered within 4-6 weeks without any residual neurodeficit. Varicella pneumonia, a dreaded usual complication of chickenpox was observed in 4% cases, causing death in 1.3% cases. The most common unusual complication of chickenpox observed was acute pancreatitis (15% cases) - almost all were young adults having mild form of the disease and occurrence of such complication was also reported in previous studies. [9],[10] Hemorrhagic vesicles, a rare complication of chickenpox was observed in this study (3.3% cases) and majority of them were elderly and/or diabetic. Necrotizing fasciitis is also a very rare and dreaded complication of chickenpox observed in 1.3% cases and also reported. [11] Acute thrombocytopenia, though an unusual complication of chickenpox, was reported in 42% cases previously, but observed only in 1.3% cases in the present study. [12],[13] All these patients had purpuric spots without other major bleeding manifestations, though central nervous system bleeding was reported earlier. [14] DIC is a rare but life threatening complication of chickenpox as observed in this study, and majority of the patients died due to uncontrolled bleeding. In this study, acute renal failure, observed in 1% of cases, was probably acyclovir induced and required discontinuation of acyclovir along with supportive dialysis. [15] Hemorrhagic stroke, an unusual and serious complication of chickenpox was diagnosed in a young boy; such complication has been reported earlier. [16] Transient cortical blindness, a very rare complication of chickenpox, was reported in only one case previously, and such complication was also observed in one patient in this study. [17] The association of nephrotic syndrome in varicella, though very rare, has been reported in past and this unusual complication was also observed in this study. [18] Acute myocarditis, a rare and dreaded complication of chickenpox, was also observed in one patient in this study. [19] One important observation was that mortality due to usual complications was 2% (0.42, 3.58), almost all were elderly and/or immunocompromised, whereas the mortality was 4% (1.78, 6.22) due to unusual complications, and the majority of such patients were immunocompetent young adults. So, unusual complications were responsible for higher mortality than the usual complications and also occurring more in patients without any risk factors.

Hence, compulsory childhood varicella vaccination including vaccination of the risk groups (elderly, persons with chronic lung diseases, diabetes, hypertension, or ischemic heart disease, and other susceptible persons) must be implemented to reduce the incidence, complications, hospitalization, and death. Besides, all patients suffering from chickenpox should be closely monitored and followed up for development of any complication even after the desquamation of rash.

 
 :: References Top

1.Wilkins EG, Leen CL, McKendrick MW, Carrington D. Management of chickenpox in the adult. A review prepared for the UK Advisory Group on Chickenpox on behalf of the British Society for the Study of Infection. J Infect 1998;1:48-9.  Back to cited text no. 1
    
2.Rawson H, Crampin A, Noah N. Deaths from chickenpox in England and Wales 1995-7: Analysis of routine mortality data. BMJ 2001;323:1091-3.  Back to cited text no. 2
    
3.Weller TH. Varicella: Historical perspectives and clinical overview. J Infect Dis 1996;174:S306-9.  Back to cited text no. 3
    
4.Zhou F, Harpaz R, Jumaan AO, Winston CA, Shefer A. Impact of varicella vaccination on health care utilization. JAMA 2005;294:797-802.  Back to cited text no. 4
    
5.Puri S, Bhatia V, Singh A, Swami HM, Kaur A. Uptake of newer vaccines in Chandigarh. Indian J Pediatr 2007;74:47-50.  Back to cited text no. 5
    
6.Leung AK, Robson WL. Orchitis as a complication of chicken pox. Br J Gen Pract 1991;41:130.  Back to cited text no. 6
    
7.Samyn B, Grunebaum L, Amiral J, Ammouche C, Lounis K, Eicher E, et al. Post-varicella cerebral thrombophlebitis with anti-protein S: Report of a pediatric case. Ann Biol Clin (Paris) 2012;70:99-103.  Back to cited text no. 7
    
8.Dits H, Frans E, Wilmer A, Van Ranst M, Fevery J, Bobbaers H. Varicella-zoster virus infection associated with acute liver failure. Clin Infect Dis 1998;27:209-10.  Back to cited text no. 8
    
9.Franco J, Fernandes R, Oliveira M, Alves AD, Braga M, Soares I, et al. Acute pancreatitis associated with varicella infection in an immunocompetent child. J Paediatr Child Health 2009;45:547-8.  Back to cited text no. 9
    
10.Kumar S, Jain AP, Pandit AK. Acute pancreatitis: Rare complication of chicken pox in an immunocompetent host. Saudi J Gastroenterol 2007;13:138-40.  Back to cited text no. 10
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11.Clark P, Davidson D, Letts M, Lawton L, Jawadi A. Necrotizing fasciitis secondary to chickenpox infection in children. Can J Surg 2003;46:9-14.  Back to cited text no. 11
    
12.Abro AH, Ustadi AM, Das K, Abdou AM, Hussaini HS, Chandra FS. Chickenpox: Presentation and complications in adults. J Pak Med Assoc 2009;59:828-31.  Back to cited text no. 12
    
13.Feusner JH, Slichter SJ, Harker LA. Mechanisms of thrombocytopenia in varicella. Am J Hematol 1979;7:255-64.  Back to cited text no. 13
    
14.Marcus KA, Halbertsma FJ, Ten WE. Fatal intracerebral hemorrhage caused by varicella-induced thrombocytopenia. Pediatr Infect Dis J 2007;26:1075.  Back to cited text no. 14
    
15.Becker BN, Fall P, Hall C, Milam D, Leonard J, Glick A, et al. Rapidly progressive acute renal failure due to acyclovir: Case report and review of literature. Am J Kidney Dis 1993;22:611-5.  Back to cited text no. 15
    
16.Fikrig E, Barg NL. Varicella associated intracerebral hemorrhage in the absence of thrombocytopenia. Diagn Microbiol Infect Dis 1989;12:357-9.  Back to cited text no. 16
    
17.Ashrafuddin S, Talib SH, Singh D, Maria DL.Varicella encephalitis with cortical blindness. Indian J Ophthalmol 1974;22:40-1.  Back to cited text no. 17
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18.Krebs RA, Burvant MU. Nephrotic syndrome in association with varicella. JAMA 1972;222:325-6.  Back to cited text no. 18
    
19.O'Grady MJ, Moylett E. Cardiac-related varicella mortality in childhood: A literature review with clinical experience. Pediatr Cardiol 2011;32:1241-3.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]

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