Varicella-zoster virus

  • This colored transmission electron micrograph (TEM) shows three virions of the varicella-zoster virus (VZV). VZV is a highly contagious virus that spreads from person-to-person by coughing or sneezing or through direct contact with the characteristic skin lesions it causes or fluids from blisters on an infected person. It takes between 10 and 21 days for a person who contracts VZV to develop symptoms.

  • Chickenpox occurs after initial exposure and is typically a mild, self-limited childhood illness. Pain and paresthesia are usually the first symptoms in the prodromal period, which occurs more often in adults than children. Infected individuals are contagious one to two days before the characteristic, itchy, vesicular rash appears and approximately four to five days afterwards.

  • Initially, erythematous macules appear accompanied by low-grade fever and malaise. These progress to papules, clear vesicles, and pustules, eventually umbilicating and crusting over. About 90% of patients report pain during acute illness. Another 19% report depression and illness, and 12% experience flu-like symptoms.

  • After initial infection, VZV remains dormant in sensory nerve roots for the remainder of a patient’s life and can be reactivated if the immune system is compromised either by medication, illness, malnutrition or naturally with aging. Shingles is the most common presentation with reactivated VZV.

  • Patients with shingles typically report a prodromal period with pain, pruritus, burning and/or parasthesias. Over the course of days erythematous macules and papules develop along a single dermatome, which then progress to vesicles that eventually crust and heal.

  • Ramsay Hunt syndrome, or herpes zoster oticus, is a reactivation of VZV that involves the facial nerve and begins with pain deep within the ear that radiates to the pinna. Vesiculations and ulcerations of the external ear and ipsilateral anterior two thirds of the tongue and soft palate are typical. Other reported symptoms include facial paresis/palsy, vertigo, hearing loss, tinnitus, headaches, otalgia, dysarthria, gait ataxia, fever and/or cervical adenopathy.

  • Another form of VZV reactivation is herpes zoster ophthalmicus, a manifestation involving the ophthalmic division of the trigeminal nerve that affects approximately 10% to 25% of patients with shingles. Patients with optical involvement such as keratitis, scleritis, iritis, orbital vasculitis should be referred to an opthalmologist immediately.

  • A two-dose varicella vaccine (Varivax) is available and currently recommended for people who have never had chickenpox. Children aged 12 months to 15 months should be administered a first dose, with a second dose recommended for children aged 4 to 6 years. The second dose can be administered earlier as long as at least 3 months have passed since the first dose. People aged 13 years and older who have never had chickenpox or received the varicella vaccine should receive the two doses at least 28

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Varicella-zoster virus a common virus responsible for a wide range of dermatologic and neurologic manifestions, including chickenpox, shingles, postherpetic neuralgia, aseptic meningitis and encephalitis, Ramsay Hunt syndrome and herpes ophthalmicus.

Before the FDA approved a live-attenuated varicella virus vaccine (Varivax, Merck) the CDC estimates approximately 11,000 people were hospitalized and an estimated 100 people died each year from chickenpox. A live-attenuated varicella-zoster vaccine (Zostavax, Merck) is also available to prevent shingles in older adults.

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