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Clinical Infection & Immunity

Case Report

Volume 4, Number 2, October 2019, pages 40-43

Varicella Infection in Pregnancy: Two Cases With Herpes Zoster and Literature Review

Varicella zoster virus (VZV) is a highly contagious deoxyribonucleic acid (DNA) virus which is transmitted by direct contact and through respiratory droplets.

Almost 90% of infections occur before 10 years of age. The disease is called varicella or “chickenpox” and the immunity acquired is life lasting. Pregnant women who are not immune to VZV should be educated to avoid exposure to infected persons as the infection could have serious consequences on mother herself and the fetus as well.

Reactivation of latent VZV results in herpes zoster (HZ) infection. Due to maternal immunoglobulin G (IgG) antibodies, this condition is less harmful for both mother and fetus.

A 38-year-old woman, gravida 2, para 1 (G2 P1), with 13 weeks pregnancy was admitted to dermatology unit because of the appearance of a frontal skin vesicular rash on an erythematous-edematous plaque associated with moderate pain (Fig. 1). No other symptoms were present.

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Figure 1. Frontal herpes zoster eruption.

Based on her personal history of varicella in childhood, characteristic eruption as well as the presence of the specific IgG antibodies to varicella, the diagnosis formulated was ophthalmic HZ.

The patient was reassured for the safety of her fetus. Treatment recommended was acyclovir 800 mg five times a day for a period of 7 days associated with topical treatment for skin lesions. No complication was recorded. The skin rash disappeared after 15 days.

Ultrasound scans during pregnancy revealed a normal developing fetus. Finally, the patient gave birth at 39 weeks of gestation to a healthy male baby of 3,250 g, with Apgar score 9.

A 27-year-old woman, G2 P2, 16 weeks pregnancy with unilateral skin rash with lesions in different stages of evolution raging from patches covered with pustules to patches with erosions covered with crusts, corresponding to T10 and T11 dermatomes associated with mild to moderate pain (Fig. 2). First lesions appeared 6 days before presentation. She also developed varicella in childhood, and the specific IgG antibodies were positive as well.

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Figure 2. Herpes zoster eruption day 3 from the onset in T10 and T11 dermatomes.

Due to the fact that she presented after more than 72 h from the onset of the specific eruption, it was recommended only topical treatment. She was reassured about the safety of her pregnancy.

The skin lesions disappeared within next 7 days, and no other event was recorded later. She gave birth to a healthy female baby weighting 3,000 g, with Apgar score 9.

Although 90% of VZV infections occur in childhood, epidemiological studies revealed that a significant number of women of reproductive age do not have VZV-specific IgG antibodies. Thus, according to Sauerbrei and Wutzler (2005), up to 26% of young women are susceptible for this infection during pregnancy [1]. The number of cases of VZV infection is higher in countries with tropical and subtropical weather conditions [2]. Moreover, VZV-specific antibodies have been identified in more women coming from Western European countries than from Central and Eastern Europe, Asia or Africa [3].

The incidence of VZV infection through pregnant women is reported as high as two to three cases in 1,000 pregnancies [4].

The clinical course of varicella in childhood is usually mild. In contrast, it is more severe in adults and particularly in the third trimester of pregnant women; and this is because of the intense immunosuppression [5].

VZV infection during pregnancy is associated with greater maternal morbidity and mortality. Varicella pneumonia, which can occur in up to 10% of cases, is more severe than in non-pregnant women, and the severity of this complication seems to increase with gestational age [6]. Since the mortality rate associated with varicella pneumonia is reported by some authors to be as high as 40% [7], this complication in pregnancy must be considered a medical emergency and treated accordingly.

Moreover, varicella encephalitis, which can occur up to 21 days after the onset of skin rash, is associated with mortality rate of up to 20% of cases [8].

Other complications such as acute thrombocytopenia, hepatitis, myocarditis and pericarditis, although rare, are also associated with high mortality rates.

VZV infection acquired in pregnancy may have serious complications on fetus as well. The virus can reach the fetus either by transplacental route during maternal viraemia periods or by ascending route from the skin lesions into the birth canal.

Fetal outcome very much depends on gestational age at the moment of infection and could be represented by fetal malformation, spontaneous abortion, premature delivery, fetal growth restriction or postnatal infection. Table 1 presents the potential consequences of VZV infection during pregnancy [9].

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Table 1. Consequences of VZV Infection During Pregnancy

Congenital varicella syndrome (CVS) was first reported in 1947 by Laforet and Lynch. Epidemiologic studies have shown that the incidence of CVS after maternal varicella infection in the first 20 weeks of gestation is less than 2% [10, 11]. Maternal VZV infection acquired before 5 weeks of gestation or after 24 weeks is associated with an extremely low risk of CVZ [9]. After Tan and Koren, the incidence of CVS is 0.55% when the maternal infection is acquired in the first trimester of pregnancy, 1.4% in the second trimester, and 0% in the third trimester [6].

CVS is characterized by serious defects and consequences. There are cutaneous defects and skin scars with dermatomal distribution. Neurologic impairment is serious and probably due to intrauterine VZV encephalitis (cortical atrophy, spinal cord atrophy, limb paresis, seizures, microcephaly, Horner’s syndrome, encephalitis, and mental retardation) [12]. Ocular disorders are also possible and this includes microphthalmia, anophthalmia, chorioretinitis, cataract, nystagmus, anisocoria and optic atrophy. Skeletal anomalies such as limb hypoplasia or diminished limb growth were also reported. Less frequent anomalies are represented by muscle hypoplasia, gastrointestinal, genitourinary and cardiovascular malformations [9].

The criteria for diagnosis of CVS are presented in Table 2 [9].

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Table 2. CVS Criteria for Diagnosis

The prognosis of infants born with CVS is poor, almost 30% of these die within the first month of life [2].

HZ is caused by reactivation of latent VZV infection in the sensitive nerve root ganglia. It usually occurs in elderly and immunocompromised individuals. HZ is characterized by a painful unilateral vesicular rash usually with dermatomal distribution on the trunk or face. The lesions tend to coalesce and may be present for days to weeks. The vesicular fluid is full of infecting virus so that, during this period, the patients are very contagious.

Little is known about the maternal and fetal risks in developing HZ in pregnancy. Most reports have shown no association with birth defects [10, 13], and this is explained by the passive placental transfer of maternal antibodies that protect the fetus from acute infection. Moreover, these antibodies persist in the newborns for up to 6 months of life.

In more than 470 cases of HZ in the first and second trimesters of pregnancy reported, there was no case of CVS identified [2, 4, 11, 13].

Due to very serious complications for both mother and fetus, every pregnant woman should have a blood test in order to assess the presence or absence of the specific IgG antibodies to varicella.

If VZV infection is diagnosed during pregnancy, an appropriate treatment should be offered and this would be decided by a multidisciplinary team which includes the obstetrician, infectionist and neonatologist as well.

Most pregnant women with varicella infection do not require hospitalization unless respiratory and/or neurological symptoms occur. There is a wide-spreading hemorrhagic rash or bleeding or new lesions appear after 6 days from the onset of eruption [14].

The only safe therapeutic agent indicated for pregnant women with varicella is acyclovir administered in a dosage of 800 mg, five times a day for 7 days. It will reduce the severity of symptoms if it is started in the first 24 h from the onset of eruption. Intravenous acyclovir in dosage of 10 mg/kg, three times a day for 7 to 10 days is indicated in severe or complicated cases [14, 15].

Varicella zoster immunoglobulin (VZIG) has no therapeutic benefit once varicella has developed [16]. It must be administered to pregnant non-immune women in the first 72 - 96 h from exposure in order to reduce the severity of maternal disease as well as the risk of fetal infection before 20 weeks of gestation.

Symptomatic treatment such as anti-inflammatory or antihistaminic drugs should be used with caution during pregnancy.

Delivery during viraemic period is extremely hazardous so that, when possible, this should be delayed until 5 days after the onset of the disease. If Caesarean section is needed, the type of anesthesia is very important since the general anesthesia may exacerbate varicella pneumonia and spinal anesthesia could increase the risk of transmitting the virus from skin lesions to central nervous system. It seems that epidural anesthesia is safer since no penetration of dura is produced [17].

The two cases presented reflect actually the concern of both mother and medical team (obstetrician, dermatologist, pediatrician and infectionist) on an actual question: is the fetus affected by this disease?

This is true since there are not many reports in the literature regarding HZ in pregnancy. Taking into consideration the good outcome of our patients as well as other clinical reports, we conclude that reactivation of VZV in pregnancy should not affect the fetus.

In addition and in accord with the decreasing number of immunized people in Romania in recent years, we strongly recommend the immunization of all children. This is more relevant since the varicella vaccine is not allowed in pregnancy, and also pregnancy should be avoided for a period of 3 months after the last dose of vaccine.

Acknowledgments

None to declare.

Financial Disclosure

None to declare.

Conflict of Interest

None to declare.

Informed Consent

Not applicable.

Author Contributions

Bogdan I. Stefanescu contributed to conception and design of the study as well as to analysis and interpretation of data and final revising of the article. Mariana Bratu contributed to acquisition and analysis of data and drafting the article. Roxana M. Stefanescu contributed to analysis and interpretation of data and revising the article. All authors have contributed to the care of these patients.

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