Neonatal varicella: varicella zoster immunoglobulin (VZIG) does not prevent disease

Abstract

Two infants with severe varicella are reported. They received varicella zoster immunoglobulin (VZIG) without concurrent information to parents or carers regarding further care. In both these cases there was a three day delay between the onset of symptoms and initiation of aciclovir. This delay was due to lack of awareness of the high risk of varicella in these infants.Infants born to mothers with onset of chickenpox 4 days before to 2 days after delivery are at risk of fatal varicella, despite the use of VZIG prophylaxis. (Arch Dis Child Fetal Neonatal Ed 1999;81:F69-F70) Keywords: varicella zoster; immunoglobulin; prophylaxis Case reports CASE 1An Asian infant boy was taken to the local hospital at 11 days of age, by which time he had had a three day history of increasing feeding diYculties and lethargy. On the day of admission he developed diarrhoea and a rash. He had been delivered at term, one day after his mother had developed varicella. The baby had been given 250 mg intramuscular varicella zoster immunoglobulin (VZIG) at 4 hours of age and was breastfed.Examination showed that the baby had respiratory failure, was shocked, and jaundiced. He had an extensive erythematous maculo-papular rash with one vesicle present. He required immediate intubation, ventilation, and circulatory support and was given intravenous aciclovir and broad spectrum antibiotics.He required six days of ventilation, including three days of high frequency oscillatory ventilation (HFOV). Once extubated, he required facial oxygen for a further week.Immunofluorescence on endotracheal aspirate was strongly positive for varicella zoster virus (VZV), and VZV DNA was demonstrated by polymerase chain reaction of endotracheal aspirate, cerebrospinal and vesicle fluids. There were no positive bacterial cultures. The baby received a total of 16 days of intravenous aciclovir and made a complete recovery. He remained well 20 months later. CASE 2An Asian boy was delivered normally at term, two days after his mother developed varicella. He was given 250 mg intramuscular VZIG on day 1. He first developed a rash at 10 days of age and was seen by the family practioner, who diagnosed heat rash. The rash persisted and two days later he again saw the GP, who prescribed calamine lotion and paracetamol. He became increasingly unwell and presented to the local accident and emergency department the following day with respiratory distress, irritability, poor feeding and hypoglycaemia. He had an extensive erythematous maculo-papular and vesicular rash. He required fluid resuscitation, intubation, and ventilation. He was ventilated for 14 days, including nine days of HFOV. He required intermittent nasal continuous positive airway pressure (nCPAP) for a further 12 days, and subsequently low flow oxygen via nasal cannulae for six weeks. He developed pancytopenia and clotting derangement and was treated with granulocyte colony stimulating factor, intravenous immunoglobulin, and received several blood transfusions.The baby also developed seizures. Computed...

Varicella infection in a neonate with subsequent staphylococcal scalded skin syndrome and fatal shock

“…However, VZIG does not always prevent disease in the newborn; rather it may modify the clinical course by prolonging the incubation period, decreasing the severity and appearance of atypical rashes. Therefore, following treatment, these newborns should be under vigilance for an extended period of 30 days and on development of any sort of rash intravenous acyclovir should be considered 2 12. Prophylactic intravenous acyclovir can prevent neonatal varicella or reduce disease severity; however, further evidence is required 13 14…”

Chickenpox, pregnancy and the newborn

“…Severe neonatal infection can occur despite VZIG administration 33. Therefore, intravenous aciclovir should be given to babies born in the highest risk period for severe disease (i.e.…”

Neonatal Varicella

“…32,43 When a neonate who has received VZIG is discharged home, it should be made clear to the parents that prompt hospital review should be undertaken if the baby becomes unwell or develops rash. 28 Passive immunization of the newborn may modify the clinical course of neonatal varicella but it does not prevent the disease and, although decreased, the risk of death is not eliminated. 16,27,44 Therefore, acyclovir therapy should be administered promptly at a dosage of 10 to 15 mg/kg every 8 hours intravenously for 5 to 7 days on suspicion of neonatal chickenpox.…”