CASE PRESENTATION

VARICELLA

Presentant
Ratna Kurnianingsi
1102012228

dr. Ulynar M, Sp.A

Faculty of Medicine YARSI
Pediatric Department
Bhayangkara Tk. I R. Said Sukanto Hospital
 • Patient’s
Identity
Name : Child AAMM
Birth Date : Januart 10st, 2016
Age : 1 years 11 months
Gender : Female
Address : Kober street RT 002/002,
Kramat Jati,East of Jakarta
Nationality : Indonesian
Religion : Islam
MR No. : 907789
Date of admission : December 9th, 2017
Date of examination : December 10th, 2017
 • Parent’s
Identity
Father Mother

Name Mr. M Mrs. D

Age 28 years old 26 years old

Job Entrepreneur Housewife

Nationality Indonesian Indonesian

Religion Islam Islam

Education High school High school

Address Kober street RT 002/002, Balekambang,

Kramat Jati

Chief Complaint
Rash that contains fluid filled
blisters on the skin since 1 day
before admission to the hospital.
Additional Complaint
Fever, coughs and colds
Anamnesis
The anamnesis was taken on
December 10th, 2017 using
alloanamnesis method. It was
taken at room No.I Anggrek 2
Ward, Bhayangkara Tk. I Raden
Said Sukanto Hospital, Jakarta.
 History of Present Illness

3 days before 1 day before

admission admission
• Appears rash that
contains fluid filled
blisters on the
Colds and dry Cough Fever patient's skin.
fever is not too high and • The blisters appeared
temperature is settled. on the back then
The patient temperature spread to the waist,
37.7oC and patients have abdomen and face.
not taken any drugs to • The bliters feels itchy.
lowering the fever.
 History of Past Illness
History of Past Illness History of Past Illness

Pharyngitis/Tonsilitis - Diarrhea -

Bronchitis - Thypoid -
Pneumonia -
Worms -
Morbilli -
Surgery -
Varicella -
Brain Concussion -
Diphteria -
Fracture -
Enteritis -
Drug Reaction -
Bacillary Dysentry -
Febril seizure -
Amoeba Dysentry -
 Allergic History
The patient have no allergy to medicine
and food.

Mother’s Pregnancy History

• Antenatal Care
Mother checkups her pregnancy to midwife
monthly
• Pregnancy Illness
No history of problems and diseases during
pregnancy
• Drug Consumed
Mother get vitamins every antenatal care
Child’s Birth History
• Labor : Local clinic
• Birth attendants : Midwife
• Mode of delivery : Vaginal birth
• Gestation : 39 weeks
• Infant state : Healthy
• Birth weight : 3200 grams
• Body length : 48 cm
• According to the mother, the baby started to
cry, the baby’s skin is red, and no congenital
defects were reported.
 Development History
Psychomotor development
Social Personality
Language
Smile: 2 months
Slant : 2 months
Reaching toys: 4
Speech initiation : 2 Screaming: 3 months
months
months Laughing : 3 months
Drinking from cup: 6
Prone position : 4 months Turn one’s head: 4
months
Sitting: 8 months months
Clapping hands: 4
Crawling : 7 months Papa/Mama: 7 months
months
Standing : 10 months
Walking : 14 months

Developmental in the normal limits and

appropriate according to the patient’s age.
Immunization History
Immunization Frequency Time

BCG 1 time 1 month old

Hepatitis B 3 times 0, 1, 6 months old

History of Eating
DPT 3 times 2, 4, 6 months old
- Breast milk : Until now
- Formula milk : SGM
Polio 4 times 0, 2, 4, 6 months
- Baby biscuit : Milna
old - Fruit and vegetables : Banana, papaya
Measles 1 times 9 months
 Family Illness History
2 weeks before, the patient's
mother was sick of chickenpox

History of Sibling
• The patient is the first child of the family
• The patient has no sibling
• Born died : (-)
• Child dies : (-)
• Miscarriage : (-)
 PHYSICAL EXAMINATION
December, 10th 2017

General Status
- General condition : Mildly ill
- Consciousness : Compos Mentis
- Pulse : 134 x/min
- Breathing rate : 24 x/min
- Temperature : 36,5 °C per axilla

Anthropometry Status
- Weight : 10 kg
- Height : 82 cm
 Nutritional
Status
Based on NCHS (National Center for
Health Statistics) year 2000 :

• WFA (Weight for Age) : 10/11,8 x 100 %

= 85 % (good nutrition)
• HFA (Height for Age) : 82/85 x 100 % =
96 % (good nutrition)
• WFH (Weight for Height) : 10/11,4 x 100 %
= 88% (good noutrition)

Conclusion : the patient

has a good nutritional
status
Head to Toe Examination
• Head
Normocephal, hair (black, normal distribution, not easily
removed), no sign of trauma.
there is a vesicle s on the forehead
• Eyes
Scleral icterus -/-, pale conjunctiva -/-, lacrimation -/-, pupil
3mm/3mm, isocor, direct light response +/+, indirect light
response +/+.
• Ears
Normal shape, no wound, no bleeding, no secretion, no
cerumen.
• Nose
Normal shape, midline septum, secretion -/-. dry bloody secret
+/-
• Mouth
Lip : dry
Teeth : 16
Mucous : moist
Tongue : No dirty
Tonsils : T1/T1, no hyperemia
Pharinx : no hyperemia
• Neck
Lymph node enlargement (-), scrofuloderma (-).
• Thorax
Inspection : Symmetric when breathing, retraction (-), ictus
cordis is not visible
Palpation : Fremitus tactile +/+ symmetric, mass (-)
Percussion : Sonor on both lungs
Auscultation :
Cor : S1-S2 regular, murmur (-), gallop (-)
Pulmo : vesicular +/+, rhonchi -/-, wheezing -/-
• Abdomen
Inspection : Relax, spider nevi (-), mass (-)
there is some vesicles
Palpation : Abdominal mass (-), hepatomegaly (-),
splenomegaly (-)
Percussion : tympanic, shifting dullness (-)
Auscultation : Increased bowel sound, bruit (-)
• Vertebra
There is no scoliosis, kyphosis, lordosis, and any mass along the
vertebral line.
• Extremity
Warm, capillary refill time <2 second, edema -/-
 Neurogical
Examination Motoric Examination
Meningeal Sign Pathologic Reflex
Upper extremities
-Hoffman - / -
Nuchal rigidity (-) -Trommer - / -
Kernig sign Lower extremities
(-)
-Babinsky - / -
Lasegue sign (-) -Chaddock - / -
-Oppenheim - / -
Brudzinski I (-) -Gordon - / -
Brudzinski II (-) -Schaeffer - / -

Power
-Hand 5 5 5 5 / 5 5 5 5
-Feet 5 5 5 5 / 5 5 5 5

Tonus
-Hand Normotonus/ Normotonus
-Feet Normotonus / Normotonus
Trophy
-Hand Normotrophy / Normotrophy
-Feet Normotrophy / Normotrophy
 Autonomic
Examination

Defecation Normal (frequency 1 times

daily)
Urination Normal (4-5 times daily)
Sweating Normal
 Laboratory
Investigation
December, 9th 2017

Results Normal Value

Hemoglobin 10,2 12 – 14 g/dl
White blood cells 10.400 5.000 – 10.000 u/l
Hematocrit 31 37 – 43 %

Platelet count 357.000 150.000 –400.000 /ul

 Working Diagnosis

1. Varicella
2. Normal Growth Status
3. Good Nutritional Status
 Management

IVFD RL 1000cc/24hours
Acyclovir 3x20 mg
Paracetamol syr 1 x 1 cth
Cetirizin 1 x 1 ampul
Ambroxol syr 3 x 2,5 ml
Cefotaxime 2 x 500 mg IV
Salicyl powder
PROGNOSIS

Quo ad vitam
dubia ad bonam

Quo ad fungsionam
dubia ad bonam

Quo ad sanactionam
Dubia ad bonam
 Cough
S Colds
Fluid filled spots on the skin, itchy

Consciousness : Compos Mentis

General condition: Midly ill
Temperature :37,1 °C
Pulse :121 x/min
Respiratory rate : 24 x/min FOLLOW UP
Head : Normocephal, On the forehead there are some vesicles December 10th 2017, 2nd day of
Eyes : Pale conjungtiva (-), icteric sklera (-), sunken eyes (-), hospitalization, 3rd day of illness
Mouth : Dry lips, moist mucous, tonsils T1/T1, hyperemia pharynx (-)
Pulmonary: Vesicular +/+, rhonchi -/-, wheezing -/-, retraction +
Cardio : S1 S2 regullar, murmur (-), gallop (-)
Abdomen : Distention (-), bowel sound (+) normal,shifting dullness (-), there is
some vesicles
Extremity: Warm, CRT <2 seconds

Varicella
A
Normal nutritional and development status

- IVFD RL 1000cc/24hours
P - Acyclovir 3 x 20 mg
- Ambroxol syr 3 x 2,5 ml
 Cough
S Colds
Fluid filled spots on the skin, itchy

Consciousness : Compos Mentis

General condition: Midly ill
Temperature :36,8 °C
Pulse :114 x/min
Respiratory rate : 23 x/min
Head : Normocephal, On the forehead there are some vesicles
Eyes : Pale conjungtiva (-), icteric sklera (-), sunken eyes (-), FOLLOW UP
Mouth : Dry lips, moist mucous, tonsils T1/T1, hyperemia pharynx (-) December 11th 2017, 3rd day of
Pulmonary: Vesicular +/+, rhonchi -/-, wheezing -/-, retraction +
hospitalization, 4th day of illness
Cardio : S1 S2 regullar, murmur (-), gallop (-)
Abdomen : Distention (-), bowel sound (+) normal, shifting dullness (-), there is some
vesicles
Extremity: Warm, CRT <2 seconds

Varicella
A
Normal nutritional and development status

- IVFD RL 1000cc/24hours
- Acyclovir 3 x 20 mg
- Ambroxol syr 3 x 2,5 ml
P - Paracetamol syr 1 x 5 ml
- Cetirizin 1 x 1 ampul
- Cefotaxime 2 x 500 mg
- Salicyl powder
 Cough
S Colds
Fluid filled spots on the skin, itchy

Consciousness : Compos Mentis

General condition: Midly ill
Temperature :36,8 °C
Pulse :114 x/min
Respiratory rate : 23 x/min
Head : Normocephal, On the forehead there are some vesicles
Eyes : Pale conjungtiva (-), icteric sklera (-), sunken eyes (-), FOLLOW UP
Mouth : Dry lips, moist mucous, tonsils T1/T1, hyperemia pharynx (-) December 12th 2017, 3rd day of
Pulmonary: Vesicular +/+, rhonchi -/-, wheezing -/-, retraction +
hospitalization, 4th day of illness
Cardio : S1 S2 regullar, murmur (-), gallop (-)
Abdomen : Distention (-), bowel sound (+) normal, shifting dullness (-), there is some
vesicles
Extremity: Warm, CRT <2 seconds

Varicella
A
Normal nutritional and development status

- IVFD RL 1000cc/24hours
- Acyclovir 3 x 20 mg
- Ambroxol syr 3 x 2,5 ml
P - Paracetamol syr 1 x 5 ml
- Cetirizin 1 x 1 ampul
- Cefotaxime 2 x 500 mg
- Salicyl powder
Literature
Review and
Discussion
 Definition
Varicella (Chickenpox) is a primary
acute infection by Varicella Zoster
Virus that attacks the skin and
mucosa
 Etiology

Varicella Zooster Virus (VZV)

• Diameter of approximately 150 - 200
nm.
• The virus core is called an icosahedral-
shaped capsid,
• Core: protein and double-chain DNA
• Tegument Protein -virus replication.
- Infectious nature
• Replication  (4-10 hours) expression
of viral proteins and formation of
multinucleated giant cells
Patogenesis
 CLINICAL MANIFESTATIONS
Prodromal Stadium
10-21 days  1-3 hr fever, chills,
headache, anorexia and malaise
Eruption Stadium
• 1-2 days -> skin rash "dew drops on rose
petals" (face, neck, head, body and
extremities) accompanied by itching
• Dispersion from the center to the periphery
 macules, papules, vesicles, pustules,
and crusts
• Cloudy vesicle liquid due to inflammatory
cell sebukan (PMN)  Pustul  Crust
• Crusta release 1-3 weeks depending on the
skin disorder.
• Skin lesions are limited in epidermal tissue
-> 7-10 days of healing
 Varicella in pregnancy
• Varicella 21 days before delivery  25% of
children -> congenital varicella in 0-5 days, mild,
rarely death
• Varicella 4-5 days before delivery  neonate 
congenital varicella 5-19 days, severe varicella
and death 25-30%
• Child of the varicella mother during pregnancy, or
varicella infant during the first month herpes
zoster < 2 years >>
 Diagnosa

• Can be enforced clinically distinctive skin lesion

description
• Appears after a short & light prodromal period
• Changes in rapid lesions of macules, vesicles, pustules to
crusts
• The presence of all levels of skin lesions at the same time
in the same area
• There are oral mucosal lesions
• Generally Laboratory examination is not needed anymore
 Complications

Secondary infection with bacteria caused

by staphylococci: impetigo, cellulitis,
fascitis, erysipelas, furuncle, abscess,
scarlet fever, or sepsis

Reye syndrome -> lethargy, nausea, persistent

vomiting, confusion and sensory changes.

Varicella Pneumonia ->

immunocompromised patients, and
pregnancy -> high heat, cough, shortness
of breath, takipneu, wet rhythm, cyanosis,
and hemoptoe a few days after the rash.
X-ray radio-opaque radiographs on both
lungs
 Treatment

Non-Medical Management:
• Isolation to prevent transmission
• When the fever is high, compress with warm water
• Try not to break the vesicles -> use powder
• Do not scratch the vesicles
• Nails should not be left long
• If you want to dry the body, just put a towel on the skin, Do not be rubbed

Medical Management:
• Symptomatic - Antipyretics
• Antihistamines
• Shake Powder (lotio calamine) -> to reduce itching
• Acyclovir:
- Neonates: 500 mg / m2 iv every 8 hours, for 10 days
- Child (2-12 years) 20 mg / kg (max 800 mg) 4-5 times daily
for 5-10 days.
• Topical antibiotics (reducing infected rash)
 Prevention

Vaccinations
• Protection of varicella up to 71 - 100%
• More effective in children after> 1 year.
• <13 years -> single dose
• > 13 Years -> Two doses are given with
intervals of 4 - 8 weeks.

Varicella Zooster Immunoglobin (VZIG)

• Prophylaxis after exposure to the virus, and
especially to people at high risk
• Dose 125 IU / 10 kgBB.
• 125 IU is a minimal dose, while the maximum dose
is 625 IU and administered intramuscularly
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Indonesia.
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