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Adult deaths from chickenpox

Public Health français Reports of deaths from chickenpox CMAJ 1997;157:557 © 1997 Canadian Medical Association See also: News and analysis: Chickenpox running scared Education: Supreme Court reaffirms landmark informed-consent ruling in chickenpox case Most physicians regard varicella as a relatively benign disease. It isn't always. The US Centers for Disease Control and Prevention (CDC) recently reported 3 fatal cases of varicella in young women. 1 We summarize these cases and emphasize the importance of vaccination, early diagnosis and appropriate treatment. A classic varicella rash developed in a 23-year-old woman in good health roughly 2 weeks after her 2 young unvaccinated children had chickenpox. On day 4 after onset of the rash, shortness of breath and hemoptysis developed. On day 5 a chest x-ray showed diffuse alveolar infiltrates, and oxygen therapy and intravenous acyclovir were started. Intubation was required. The respiratory distress worsened; treatment was continued with oxygen, antibiotics and intravenous acyclovir. On day 12 the rash became hemorrhagic, and disseminated intravascular coagulation and renal failure developed. The patient died 2 days later. Varicella zoster virus was cultured from skin lesions and tracheal aspirate.
A strikingly similar case occurred in a 25-year-old previously healthy woman in whom a classic varicella rash, fever and headache developed about 2 weeks after her young unvaccinated child had chickenpox. A cough developed on day 2, followed by shortness of breath on day 3 and progressive respiratory difficulty and confusion on day 4. A chest x-ray showed bilateral infiltrates and the patient was found to be hypoxemic. Treatment with oxygen and intravenous acyclovir was started; intubation was also required. On day 6 computerized tomography of the brain showed severe, diffuse, cerebral edema. Renal failure and coma developed, and the patient died on day 7.
In the third case, a 32-year-old woman with Crohn disease presented to an emergency department with abdominal and back pain. She had recently had an exacerbation of Crohn disease that was being treated with prednisone (40 mg/d, tapered to 20 mg/d). A mild macular, nonpruritic rash on her back was ignored, and a benign abdominal syndrome was presumptively diagnosed. The abdominal pain persisted, and the patient was admitted to hospital on day 3; her white blood cell count was elevated, and a maculopapular vesicular rash with crusted lesions was observed on her trunk, head and neck. Varicella was presumptively diagnosed. The patient reported that 2 weeks earlier she had been exposed to her 4-year-old unvaccinated niece who had chickenpox. On day 4 the vesicles became hemorrhagic and the patient began to bleed from intravenous sites. Hypotension and disseminated intravascular coagulation rapidly developed, and the patient died from shock on the same day. Autopsy showed viral inclusion bodies, consistent with varicella, in multiple organs.
These cases illustrate that varicella is potentially fatal. Although fewer than 5% of cases occur in people over age 20, 55% of varicella-related deaths occur in this age group. The CDC recommends that all children be routinely vaccinated at age 12-18 months. The vaccine is not yet available in Canada. People at increased risk of serious complications from varicella who have been exposed to a case should be given varicella zoster immune globulin within 96 hours of exposure. The earlier the immune globulin is given, the more likely it is that the disease will be attenuated. If varicella develops in an immunocompromised patient, acyclovir should be given, preferably within 24 hours of onset of rash. Prevention is important: varicella is highly contagious, especially during the 2 days before the rash appears. In the US it is recommended that all children and susceptible adults receive the vaccine. The 3 deaths reported here could have been prevented if the children to whom the young women were exposed had been vaccinated. It is important for Canadians to have access to the vaccine, which has been used in the US since 1995, in Japan since 1984 and is used in various European countries. Health Canada should consider taking steps to encourage manufacturers to license their varicella vaccines in this country. -- JH, AMT Reference 1.Varicella-related deaths among adults -- United States, 1997. MMWR 1997;46:412-5. | CMAJ September 1, 1997 (vol 157, no 5) / JAMC le 1er septembre 1997 (vol 157, no 5)
Study: Chickenpox vaccine reduces adults’ odds of illness, complications September 8, 2000 From staff reports ATLANTA (CNN) -- A vaccine that prevents most cases of chickenpox is effective in protecting adults from brain inflammation, pneumonia and other serious complications that may occur with chickenpox, researchers announced Thursday. Immunization is recommended for adults who have not had chickenpox, the researchers said in a report for members of the Infectious Diseases Society of America, meeting this week in New Orleans. Chickenpox, usually a childhood disease, also strikes adults. They are more likely than children to experience complications and death, according to the U.S. Centers for Disease Control and Prevention (CDC). About 85 percent of adults who have not had chickenpox and haven’t been vaccinated will get the sickness when exposed to the disease, said Dr. Krow Ampofo, who led the research. The infection rate drops to about 20 percent among vaccinated adults who are later exposed to the chickenpox virus. "They have fewer complications," Ampofo said. "It’s a milder form. Recovery time is quicker." One of the most serious complications of chickenpox, especially for adults, is encephalitis. It is an inflammation of the brain that can cause loss of consciousness, seizures, muscle weakness, sudden severe dementia, memory loss, withdrawal from social interaction and impaired judgment, according to the CDC. Milder symptoms include confusion, sudden fever, headache, vomiting, photophobia (abnormal visual sensitivity to light), stiff neck, stiff back, drowsiness, clumsiness, unsteady walk and irritability. 
Ampofo, a pediatric infectious-disease specialist at Columbia Presbyterian Hospital, New York City, said rates of infections did not decrease significantly during the first three years the chickenpox vaccine was available for U.S. children, beginning in 1995. Since 1998, as more and more children were vaccinated, the incidence of chickenpox has declined, he said. As additional transmission routes are broken by the expanding use of the vaccine, the chickenpox virus finds fewer hospitable hosts. "It may become eradicated," said Ampofo. The vaccine is for healthy children 12 months of age or older and for adolescents and adults who have not had chickenpox. A simple test can determine whether a person has had the illness, Ampofo said. Usually, having the disease prevents a person from a second infection. For adults who may be susceptible to chickenpox, he recommended visiting a physician. "Despite the fact that adults account for only 5 percent of varicella (chickenpox) cases per year," a CDC report said, "they account for a disproportionate number of deaths (55 percent) and hospitalizations (33 percent) compared with children." Ampofo and his colleagues studied the cases of 557 vaccinated adults. "Among those who did contract chickenpox, the disease was generally mild with an average of 54 skin lesions or blisters," he said. A severe case may produce more than 500 lesions, and the average is about 350, according to the CDC. Chickenpox is contagious one to two days before the rash appears and until all blisters have formed scabs. Chickenpox develops within 10 to 21 days after contact with an infected person. An itchy rash develops into skin blisters that dry and become scabs in four to five days, CDC officials said. The rash, often the first sign of chickenpox, is sometimes accompanied by fever and malaise, which is usually more severe in adults. Ampofo said one complication of chickenpox is a secondary skin infection caused by bacteria. Vesicles on the face and body can result in deep scars. Before vaccinating began nationwide in 1995, there were approximately 11,000 hospitalizations and 100 deaths from chickenpox annually in the United States, CDC officials said. The cost of caring for U.S. children of normal health who contract chickenpox was estimated at $918 million in 1993, two years before introduction of the vaccine. By 1999, CDC officials detected a dramatic decline in cases and the typical springtime increase in chickenpox cases did not occur. Since chickenpox is highly contagious, more than 95 percent of Americans have gotten the disease by adulthood in pre-vaccination years. The virus spreads from person to person by direct contact or through the air, according to a CDC report. Approximately 90 percent of persons in a household who have not had chickenpox will get it if exposed to an infected family member.


Date last modified: October 16, 2007