child in the case study is suffering from varicella or, as it is commonly called, Chicken Pox. The rash was the initial presenting symptom, preceding the cellulitis by 5 days. The description is classis with the history of the infection as fever, malaise, and a generalized vesicular rash typically consisting of 250-500 lesions. The most common complications of varicella, which can result in hospitalization, are bacterial infections of skin lesions, pneumonia, dehydration, encephalitis, and hepatitis. The fever, depending on the degree of elevation combined with the speed it developed could have predisposed the child to a febrile seizure (Hamment, 1999)
Acyclovir is sometimes used to treat chicken pox, although usually not in a non-immunocompromised population without secondary infection. Acyclovir is an anti-viral medication which reduces the amount and degree of lesion formation and is felt to decrease the incidence of complication in children with varicella. It is usually most effective when provided within 24 to 48 hours of the onset of the rash.
Both the child in the case study and the health care workers caring for her are at risk because of her infection. Each vesicle provides another avenue for normal skin colonization to become pathogenic, perhaps causing cellulitis or perhaps a septicemia. Adults, who have not previously been exposed to varicella usually have more severe disease and are at higher risk for complications (Haiduven-Griffiths, Fecko, 1987)
Prevention of varicella is easier now than ever. Vaccination is recommended for all children at age one. Additionally, most adults who deny a history of varicella in childhood actually have the antibody and most likely experienced a sub-clinical infection. For those individuals who have not been exposed, vaccination should be considered, especially for those considered to be at high risk including:
Persons who live or work in environments in which transmission of VZV is likely (e.g., teachers of young children, day-care employees, and residents and staff in institutional settings).
Persons who live or work in environments in which varicella transmission can occur (e.g., college students, inmates and staff of correctional institutions, and military personnel).
Nonpregnant women of childbearing age. Vaccination of women who are not pregnant — but who may become pregnant in the future — will reduce the risk for VZV transmission to the fetus.
Interpretation of Relative History:
18-month female with fever, diffuse rash
Prime demographic for varicella infection)
Child is irritable but alert
Good sign, since toxicity would be an issue with this child. A good level of consciousness is useful in assessing the level of illness but can change quickly in the pediatric population)
Her heart rate is 180 beats per minute
She is tachycardic, but most likely due to the fever and irritability. The child is not described as tachypneic)
She had diffuse vesiculopustular lesions over her entire body, with some areas showing older, crusted lesions.
History is typical for infection with some element of the herpes family, and in this age group without dermatomal distribution, varicella is most likely.
She had cellulitis of the right hand manifested by marked erythema, swelling, and tenderness
Possible adverse event related to the vesicular disruption of intact integument)
Laboratory data were significant only for leukocytosis, with a white blood cell count of 15,800/?l with 88% neutrophils.
Not a panic level, and probably due entirely to the cellulitis)
References
Hamment, JM. (1999) Respiratory viral infection predisposing for bacterial disease: a concise review. FEMS Immunology and Medical Microbiology [FEMS Immunol. Med. Microbiol.]; 26, 189-195. 1 Dec 1999.
Haiduven-Griffiths D, Fecko H. Varicella in hospital personnel: a challenge for the infection control practitioner. Am J. Infect Control 1987; 15:207-11.
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