Chickenpox physical examination: Difference between revisions

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==Overview==
==Overview==
The diagnosis of varicella is primarily clinical. In a non-immunized individual with typical [[prodrome|prodromal]] symptoms associated with the appropriate appearing rash occurring in "crops", no further investigation would normally be undertaken.
The diagnosis of [[Chickenpox|varicella]] is primarily [[clinical]]. [[Skin]] lesions on physical examination include [[Pruritic disorders|pruritic]] [[macules]] on the [[back]], [[chest]], [[face]], [[abdomen]] and [[extremities]]. [[Skin]] lesions progress to [[papules]] and [[Healing|heal]] by crusting. The other common [[skin]] lesions include [[papules]], [[vesicles]], [[pustules]] and crusts.
 
==Physical Examination==
 
===Appearance of the Patient===
*The patient appears weak and [[tired]] with [[Rash|rashes]] spread over the [[scalp]], [[face]], [[trunk]], and [[limbs]]. The intense [[pruritis]] triggers recurrent urges to scratch.
 
===Vitals===
*Low-grade [[fever]]
*[[Tachycardia]]<ref name="pmid2464648">{{cite journal| author=Schraufnagel DE, Becker RP, Balaan M, Schmid A, Claypool W| title=Silver staining of Pneumocystis carinii in the rat's lung. | journal=J Infect | year= 1989 | volume= 18 | issue= 1 | pages= 39-44 | pmid=2464648 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2464648  }} </ref>
 
===Skin===
[[Skin]] lesions on physical examination include:
*[[Pruritus|Pruritic]] [[macules]] on the [[back]], [[chest]], [[face]], [[abdomen]] and [[extremities]].
*[[Skin]] lesions progress to [[Papule|papules]] and [[Healing|heal]] by crusting. Other common [[skin]] lesions include:
**[[Papules]]
**[[Vesicles]]
**[[Pustules]]
**Crusts
 
===HEENT===
*[[Cervical lymph nodes]]
*[[Pallor]]
*[[Skin lesions]]
*[[Oral ulcers]]
 
===Lungs===
Normal [[breath sounds]] are heard.
 
===Abdomen===
The abdomen will not be [[Tenderness (medicine)|tender]] and there is no [[organomegaly]].
===Heart===
*Normal [[S1]] and [[S2]] are heard.
*[[Ventricular fibrillation]] presumed to be secondary to [[myocarditis]] has been observed in some of the adult population. <ref name="pmid2464648">{{cite journal| author=Schraufnagel DE, Becker RP, Balaan M, Schmid A, Claypool W| title=Silver staining of Pneumocystis carinii in the rat's lung. | journal=J Infect | year= 1989 | volume= 18 | issue= 1 | pages= 39-44 | pmid=2464648 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2464648  }} </ref>
 
===CNS===
*The [[neurological examination]] may be normal with no focal neurological deficits.
*CNS may show the following findings:
:* Meningitis
:* Meningoencephalitis
:* Vasculopathy
 
==Gallery==
 
<gallery>
 
Image: Chickenpox36.jpeg| Chickenpox lesions on the skin of this patient's left breast and arm on day 6 of the illness. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox35.jpeg| Chickenpox lesions on the skin of this patient's back and buttocks at day 6 of the illness. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox34.jpeg| Chickenpox lesions on the skin of this patient's breasts, arms, and torso at day 6 of the illness. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox33.jpeg|Patient with cervical skin lesions caused by chickenpox. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox32.jpeg|4-month old infant with skin lesions on his brow ridge due to chickenpox. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox29.jpeg|Patient had presented with chickenpox demonstrating the typical rash on day eight. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox28.jpeg|Patient developed palatal mucosal lesions due to chickenpox. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
 
Image: Chickenpox27.jpeg|Vaccine recipient developed a secondary herpes infection adjacent to the vaccination site. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>


If further investigation is undertaken, confirmation of the diagnosis can be sought through either examination of the fluid within the vesicles, or by testing blood for evidence of an acute immunologic reposnse. Vesicle fluid can be examined with a Tsanck smear, or better with examination for [[direct fluorescent antibody]]. The fluid can also be "cultured", whereby attempts are made to grow the virus from a fluid sample. Blood tests can be used to identify a response to acute infection (IgM) or previous infection and subsequent immunity (IgE).<ref>McPherson & Pincus: Henry's Clinical Diagnosis and Management by Laboratory Methods, 21st ed., 2007, Chapter 54.
Image: Chickenpox26.jpeg|Pustulovesicular rash represents a generalized herpes outbreak due to the Varicella-zoster virus (VZV) pathogen. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
</ref>


Prenatal diagnosis of foetal varicella infection can be performed using [[ultrasound]], though a delay of 5 weeks following primary maternal infection is advised. A [[polymerase chain reaction|PCR]] (DNA) test of the mother's [[amniotic fluid]] can also be performed, though the risk of [[spontaneous abortion]] due to the [[amniocentesis]] procedure is higher than the risk of the baby developing foetal varicella syndrome.
Image: Chickenpox24.jpeg|Case of chickenpox. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox23.jpeg|Case of chickenpox. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox22.jpeg|Case of chickenpox. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox21.jpeg|Chickenpox lesions on a patient’s back, which were displaying the characteristic “cropping” distribution, or manifesting themselves in clusters. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox20.jpeg|Posterior view of a hospitalized man's neck, back and shoulders, who’d been assigned a bed in a smallpox ward, due to an initially misdiagnosed illness, which turned out to be chickenpox. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox19.jpeg|View of a patient’s thighs and upper legs, who’d been diagnosed with chickenpox. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox18.jpeg|Pathologic changes seen on the surface of the right unilateral side of this elderly male patient’s tongue and chin, represent a herpes outbreak due to the Varicella-zoster virus (VZV) pathogen. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox17.jpeg|Viewed from above, this image depicts a smallpox scab (left), and chickenpox scab (right) as a demonstration in comparative morphology. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>


==Physical Examination==
Image: Chickenpox16.jpeg|Close-up of a maculopapular rash that was diagnosed as a crop of chickenpox lesions. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox15.png|Lateral view of a 4 month-old infant’s face with a single varicella-zoster, otherwise known as chickenpox. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
 
Image: Chickenpox06.jpeg|This anteroposterior (AP) radiograph revealed bilateral pulmonary infiltrates throughout the entirety of each lung field in the case of a child with leukemia, as well as chickenpox pneumonia.  <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
 
Image: Chickenpox04.jpeg|Image depicts three mounted chickenpox scabs seen from the side revealing the superficiality of these scabs when morphologically compared to a smallpox scab.  <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>


===Appearance of the Patient===
Image: Chickenpox03.jpeg|Volar surface of a patient’s left forearm, including the palmar surface of the left hand upon which you’ll note classic maculopapular rash of chickenpox. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>


====Chickenpox in Unvaccinated People====
Image: Chickenpox02.jpeg|Right lateral surface of a patient’s right lower leg and foot with classic maculopapular rash of chickenpox. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>


The rash is generalized and [[pruritic]] (itchy). It progresses rapidly from [[macules]] to [[papules]] to [[vesicular lesions]] before crusting. The rash usually appears first on the [[head]], [[chest]], and [[back]] then spreads to the rest of the [[body]]. The lesions are usually most concentrated on the chest and back.
Image: VZV03.jpeg|Right lateral surface of a patient’s right lower leg and foot with classic maculopapular rash of chickenpox. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>


In healthy children, varicella is generally mild, with an itchy rash, malaise, and temperature up to 102°F for 2 to 3 days. Adults are at risk for more severe [[disease]] and have a higher incidence of complications. Recovery from primary varicella infection usually provides [[immunity]] for life. In otherwise healthy people, a second occurrence of varicella is uncommon and usually occurs in people who are [[immunocompromised]]. As with other [[viral]] infections, re-exposure to natural (wild-type) varicella may lead to re-infection that boosts [[antibody]]] [[titers]] without causing illness or detectable [[viremia]].
Image: VZV01.jpeg| Back of boy with chickenpox. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>


====Chickenpox in Vaccinated People====
Image: Varicella 01.jpeg| Varicella <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Chickenpox in people who are vaccinated is referred to as breakthrough varicella.
Image: Varicella 02.jpeg| Varicella <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Breakthrough varicella is [[infection]] with wild-type VZV occurring in a vaccinated person more than 42 days after varicella vaccination. Breakthrough varicella is usually mild. Patients typically are [[afebrile]] or have low fever and develop fewer than 50 [[skin]] lesions. They usually have a shorter illness compared to unvaccinated people who get varicella. The rash is more likely to be predominantly maculopapular rather than vesicular. However, 25%-30% of persons vaccinated with 1 dose with breakthrough varicella have clinical features typical of varicella in unvaccinated people.
Image: Varicella 03.jpeg| Varicella <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Varicella 04.jpeg| Varicella <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Varicella 05.jpeg| Varicella <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Varicella 06.jpeg| Varicella <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Varicella 07.jpeg| Varicella <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Varicella 08.jpeg| Varicella <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Varicella 10.jpeg| Vasculitis leukocytoclasia. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Varicella 11.jpeg| Vasculitis leukocytoclasia. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Varicella 12.jpeg| Vasculitis leukocytoclasia. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Varicella 13.jpeg| Vasculitis leukocytoclasia. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Varicella 14.jpeg| Vasculitis leukocytoclasia. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>


Since the clinical features of breakthrough varicella are often mild, it can be difficult to make a diagnosis on clinical presentation alone. Laboratory testing is increasingly important for confirming varicella and appropriately managing cases and their contacts. There is limited information about breakthrough varicella in persons who have received two doses of varicella vaccine, though it appears to occur less frequently among people vaccinated with two doses of varicella vaccine compared to persons who have received a single dose of varicella vaccine.
</gallery>


====Unvaccinated Individuals====
====Unvaccinated Individuals====
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Image:Chickenpox U3.jpg|Chickenpox in an unvaccinated adult.
Image:Chickenpox U3.jpg|Chickenpox in an unvaccinated adult.
Image:Chickenpox U4.jpg|Chickenpox in unvaccinated adult.
Image:Chickenpox U4.jpg|Chickenpox in unvaccinated adult.
Image:CHICKENPOX_IN_UNVACCINATED_CHILD.jpg|Chickenpox in unvaccinated child.
</gallery>
</gallery>


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Latest revision as of 20:53, 29 July 2020


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Aravind Reddy Kothagadi M.B.B.S[2]

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Overview

The diagnosis of varicella is primarily clinical. Skin lesions on physical examination include pruritic macules on the back, chest, face, abdomen and extremities. Skin lesions progress to papules and heal by crusting. The other common skin lesions include papules, vesicles, pustules and crusts.

Physical Examination

Appearance of the Patient

Vitals

Skin

Skin lesions on physical examination include:

HEENT

Lungs

Normal breath sounds are heard.

Abdomen

The abdomen will not be tender and there is no organomegaly.

Heart

CNS

  • Meningitis
  • Meningoencephalitis
  • Vasculopathy

Gallery

Unvaccinated Individuals

  • Girl with a secondary skin infection due to chickenpox.

    Girl with a secondary skin infection due to chickenpox.

  • Chickenpox in an unvaccinated child.

    Chickenpox in an unvaccinated child.

  • Chickenpox in an unvaccinated adult.

    Chickenpox in an unvaccinated adult.

  • Chickenpox in unvaccinated adult.

    Chickenpox in unvaccinated adult.

  • Chickenpox in unvaccinated child.

    Chickenpox in unvaccinated child.

Vaccinated Individuals

  • Image of Breakthrough Chickenpox: Back of child with breakthrough varicella.

    Image of Breakthrough Chickenpox: Back of child with breakthrough varicella.

  • Image of Breakthrough Chickenpox: Back of child with breakthrough varicella.

    Image of Breakthrough Chickenpox: Back of child with breakthrough varicella.

  • The skin lesions of breakthrough varicella can be macular rather than vesicular. They are rarely bullous or hemorrhagic, and residual scarring is less common.

    The skin lesions of breakthrough varicella can be macular rather than vesicular. They are rarely bullous or hemorrhagic, and residual scarring is less common.

  • Breakthrough varicella on the abdomen of a vaccinated child.

    Breakthrough varicella on the abdomen of a vaccinated child.

  • Breakthrough varicella on the back of a vaccinated child.

    Breakthrough varicella on the back of a vaccinated child.

References

  1. ↑ 1.0 1.1 Schraufnagel DE, Becker RP, Balaan M, Schmid A, Claypool W (1989). "Silver staining of Pneumocystis carinii in the rat's lung". J Infect. 18 (1): 39–44. PMID 2464648.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 2.29 2.30 2.31 2.32 2.33 2.34 2.35 2.36 2.37 "Public Health Image Library (PHIL)".


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