Caracterización clínica y de costos de la hospitalización asociada a varicela en niños de la Región Metropolitana y de Valparaíso, Chile / Clinical and cost characterization of hospitalization associated with varicella in children from the Metropolitan Region and Valparaíso, Chile

INTRODUCCIÓN: La varicela es una infección relevante en la salud pública de Chile, pudiendo causar en algunas ocasiones complicaciones graves e incluso la muerte, lo que se asocia a un significativo gasto en salud. En Chile sólo se realiza vigilancia centinela a nivel ambulatorio, sin conocerse el impacto de la varicela en casos más graves que determinan hospitalización. OBJETIVOS: Realizar una descripción clínica y de los costos asociados a la atención de niños hospitalizados con diagnóstico de varicela, en años previos a la introducción de la vacuna en el Programa Nacional de Inmunización en Chile. MATERIALES Y MÉTODOS: Estudio multicéntrico, observacional y retrospectivo, en todos los casos de niños hospitalizados (0-15 años) con diagnóstico de varicela, entre enero de 2011 y diciembre de 2015 en cinco hospitales de Chile. Se realizó revisión de fichas para evaluar características clínicas de la enfermedad y los costos asociados a la hospitalización por varicela. RESULTADOS: Un total de 685 hospitalizaciones por varicela fueron incluidas en el estudio. La mediana de edad fue de 3 años (RIC:1-5), siendo la mayoría de los niños con edades comprendidas entre los 1 y 4 años (52% del total de casos). El 56% fueron hombres y sólo 7 niño s (1%) tuvieron antecedente de vacuna varicela. La mediana de días de hospitalización fue de 3 días en cada episodio (RIC: 2-5). El 13% de los casos requirió hospitalización en unidades de mayor complejidad, 7% de los niños ingresó a Unidad de Tratamiento Intensivo y 6% ingresó a Intermedio, ambos con una mediana de 3 días de hospitalización. Las principales complicaciones fueron: infección de piel y tejidos blandos (42%), alteraciones neurológicas (8%) y shock séptico/tóxico (4%). La letalidad fue de 0,4%. El costo de un caso de varicela considerando los costos directos fue de US$417, el costo indirecto fue de US$224 y los costos proporcionales de una muerte de US$3.575. Se estima que el costo total de un caso de varicela hospitalizado en Chile, considerando todos los factores anteriores, fue de US$4.216. CONCLUSIONES: La varicela es una enfermedad inmunoprevenible frecuente. Se observaron casos con una mediana de 3 días de hospitalización por complicaciones, con 13% de los casos requiriendo hospitalización en unidades de mayor complejidad, con un alto costo asociado, que se estima podría disminuir significativamente con la reciente incorporación de la vacuna al Programa Nacional de Inmunizaciones.

BACKGROUND: Varicella is a relevant infection in Chile and may cause serious complications and death, which could be associated with significant health care resource utilization and associated costs. In Chile, sentinel surveillance is carried out only on an outpatient basis, without knowing the impact of varicella in serious cases who need to be hospitalized. AIM: To describe the clinical characteristics and the costs associated with hospitalized children with diagnosis of varicella prior to the vaccine introduction in the National Immunization Program in Chile. PATIENTS AND METHODS: A multicenter, observational, and retrospective study in hospitalized children (0-15 years) with a diagnosis of varicella, were conducted in five hospitals in Chile between January 2011 and December 2015. A review of the clinical records was performed to evaluate the clinical characteristics of the disease and costs associated with hospitalization episodes for varicella. RESULTS: A total of 685 hospitalized children for varicella were included in this study. The median age was 3 years (IQR: 1-5), most children were between 1 and 4 years of age (52% of total cases). 56% were male, and only 7 patients (1%) had a history of previous varicella vaccination. The median lenght of days of hospitalization was 3 days (IQR: 2-5). 13% of the cases required hospitalization in a more complex care unit, 6% in the intermediate unit and 7% in the pediatric intensive treatment unit, both with a median stay of 3 days. The main complications were: skin and soft tissue infections (42%), neurologic (8%) and septic or toxic shock (4%). There were 3 cases of death (0.4%). The direct cost of a varicella case was US $ 417, the indirect cost was US $ 224 and the proportional cost of a case of death was US $ 3,575. It is estimated that the total cost of a hospitalized varicella case in Chile was US $ 4,216. CONCLUSIONS: Varicella is associated with a significant burden of disease in Chile. The median hospital stay was three days with 13% of cases requiring medical care in a complex unit, with high associated costs which could be significantly reduced with the recently incorporation of the varicella vaccine into the National Immunization Program.

Rib osteomyelitis: a rare complication of varicella / Osteomielite de arco costal: uma complicação rara de varicela

ABSTRACT Objective: To report a case of varicella complicated by acute osteomyelitis in order to remind of a rare and potentially serious complication of a very common pediatric disease. Case description: A previously healthy 3-month-old female infant with 10-day history of varicella was admitted to the hospital for fever, groan and prostration. The initial laboratorial evaluation was compatible with bacterial sepsis. By the third day after admission, a swelling of the seventh left rib had developed. The ultrasound and scintigraphy evaluation suggested rib osteomyelitis. Blood cultures were negative. The patient completed six weeks of antibiotics with favorable clinical, laboratorial and imaging evolution. Comments: Varicella is one of the most frequent exanthematic diseases of childhood and it is usually self-limited. The most frequent complication is bacterial infection of cutaneous lesions. Osteoarticular complications are rare, and rib osteomyelitis is described in less than 1% of cases. The main route of dissemination is hematogenic, and the most frequent etiological agent is Staphylococcus aureus. The prognosis is generally good and depends on early detection and antibiotic initiation.

RESUMO Objetivo: Descrever um caso de varicela complicada de osteomielite aguda a fim de alertar para a complicação rara e potencialmente grave de uma doença muito frequente em idade pediátrica. Descrição do caso: Lactente de três meses, previamente saudável, internada por um quadro de febre, prostração e gemido, num contexto de varicela com cerca de dez dias de evolução, com avaliação inicial compatível com sepse de etiologia bacteriana. No terceiro dia de internação, observou-se uma tumefação na sétima costela esquerda. A avaliação ecográfica e cintilográfica mostraram alterações sugestivas de osteomielite de arco costal. As hemoculturas foram negativas. Recebeu antibioticoterapia por seis semanas e evoluiu favoravelmente do ponto de vista clínico, laboratorial e ecográfico. Comentários: A varicela é uma das doenças exantemáticas mais frequentes da infância, sendo habitualmente autolimitada. A complicação mais frequente é a infecção bacteriana secundária das lesões cutâneas, sendo raras as complicações osteoarticulares. O arcabouço costal é uma localização excepcional de osteomielite, descrita em menos de 1% dos casos. A principal via de disseminação é a hematogênica, e o agente mais frequente, o Staphylococcus aureus. O prognóstico é geralmente bom, quando a antibioticoterapia se institui precocemente.

Varicela y herpes zóster: retos para la salud pública / Varicella and herpes zoster: challenges for public health

Resumen: Objetivo: Evaluar el comportamiento epidemiológico de la varicela y el herpes zoster (HZ) para determinar políticas de salud y disminuir prevalencia y complicaciones. Material y métodos: La frecuencia de casos se estimó con datos del Sistema Único de Información para la Vigilancia Epidemiológica (SUIVE), periodo 2000-2013; para los egresos hospitalarios de varicela y HZ, se utilizaron datos del Sistema Nacional de Información en Salud (Sinais). Resultados: El promedio de casos de varicela anual fue 296 733, 57% menores de 9 años, la mayoría de marzo a mayo; de 2004 a 2012 los egresos hospitalarios de varicela fueron 17 398, de ellos 4.6% presentó meningoecefalitis, 2.5% neumonía y 18% otras complicaciones. Por herpes zoster 7 042 egresos, más afectados de 65 años o más, 1.3:1 la relación mujer:hombre. Las complicaciones: neuralgia (11%), afección ocular (7%), meningoencefalitis (5.4%), enfermedad diseminada (2.8%) y otras (5.4%); estancia hospitalaria entre 6.4 a 13.3 días. Conclusiones: Los datos coinciden con los de la literatura de otros países. Se discute el papel de la vacunación en la prevención de la infección en niños y adultos.

Abstract: Objective: To evaluate the epidemiological behavior of varicella and herpes zoster (HZ) to determine the need of health policies to diminish prevalence and avoid complications. Materials and methods: To assess frequency, we analyzed data from the National Information System for Epidemiological Surveillance (SUIVE) from 2000 to 2013; to assess the discharge data of varicella and HZ, we evaluated information from the National System of health information (Sinais). Results: The average annual cases of chickenpox were 296 733, 57% mostly children under 9 years, most of them from March to May. From 2004 to 2012 hospital discharge of varicella were 17 398, of which 4.6% had meningoecephalitis, 2.5% pneumonia and 18% other complications. For herpes zoster 7 042 discharges, mostly affected were patients 65 years or older, 1.3:1 the woman-man relationship. Main complications were: neuralgia (11%), eye involvement (7%), meningoencephalitis (5.4%), disseminated disease (2.8%) and others (5.4%); hospital stay was between 6.4 and 13.3 days. Conclusions: Data is consistent with that of the literature in other countries. The role of vaccination to prevent infection in children and adults is discussed.

Optic neuritis complicating herpes zoster ophthalmicus in an immunocompetent patient / Zoster optic neuritis in immunocompentent

A 58-year-old woman presented with rash over the left side of the face and intense acute uveitis. Following careful review of the symptoms and dilated fundus examination unilateral optic neuritis was discovered. The rash was typical of varicella zoster dermatitis. Patients presenting with herpes zoster ophthalmicus should always undergo dilated fundus examination, as there is a potential risk of unexpected posterior segment inflammation. Early diagnosis and prompt treatment can avoid visual sequelae.

Paciente de 58 anos de idade apresentando erupção cutânea no lado esquerdo da face e intensa uveíte unilateral. Após cuidadosa revisão dos sintomas e exame de fundo do olho foi detectada neurite óptica. O rash era típico de dermatite por varicella zoster. Pacientes apresentando quadro de herpes zoster oftálmico devem ser submetidos ao exame de fundo do olho devido ao risco de inesperada inflamação do segmento posterior. Diagnóstico precoce e tratamento imediato podem evitar danos visuais.

Síndrome da angústia respiratória aguda associada à varicela em paciente adulto: exemplo de suporte respiratório extracorpóreo em doenças endêmicas brasileiras / Varicella associated acute respiratory distress syndrome in an adult patient: an example for extracorporeal respiratory support in Brazilian endemic diseases

Descreveu-se aqui o caso de um homem de 30 anos de idade com quadro de varicela grave, hipoxemia refratária, vasculite do sistema nervoso central e insuficiência renal anúrica. Foi necessário transporte por ambulância com suporte respiratório extracorpóreo veno-venoso, sendo este utilizado até a recuperação do paciente. Discute-se o potencial uso de oxigenação por membrana extracorpórea em países em desenvolvimento para o controle de doenças comuns nestas áreas.

A case of a 30 year-old man presenting with severe systemic chickenpox with refractory hypoxemia, central nervous system vasculitis and anuric renal failure is described. Ambulance transportation and support using veno-venous extracorporeal membrane oxygenation were necessary until the patient recovered. Ultimately, the potential use of extracorporeal membrane oxygenation support in low-middle income countries to manage common diseases is discussed.

Fascitis necrotizante como complicación de la varicela en niños / Necrotizing fasciitis as a complication of chickenpox in children

La fascitis necrotizantees una enfermedad grave y poco frecuente. Se la ha descripto como una complicación rara dela varicela, en niños previamente sanos. Se caracteriza por una extensa necrosis de la piel y el tejido celular subcutáneo, que se extiendea las fascias y músculos subyacentes. Está vinculada a alta toxicidad sistémica y es rápidamente fatal, sino se diagnostica con celeridad. La presente revisión tiene como objetivo repasar los elementos que permiten reconocer y diagnosticar esta patología para llevar a cabo un tratamiento adecuado lo antes posible...

Necrotizing fasciitis is an uncommon but serious disease. It has been described as a rare complication of chickenpox in healthy children.It is characterized by extensive necrosis of skin and subcutaneous tissue with subsequent compromise of the fascial planes and muscles. It presents with severe systemic toxicity and is usually rapidly fatal unless diagnosed promptly and treated aggressively. The present review emphasizes the elements that guide the recognition and diagnose of the disease, in order to carry out immediate and proper treatment...

Varicela complicada en un hospital pediátrico de referencia, Perú 2001-2011 / Complicated chickenpox in a national pediatric Peruvian hospital, 2001-2011

El objetivo de estudio fue describir las características clínicas y epidemiológicas de los casos de varicela complicada atendidos en el Instituto Nacional de Salud del Niño (INSN) del Perú durante los años 2001 al 2011. Se realizó una serie de casos que incluyó un total de 1073 niños con varicela complicada. La mediana de la edad fue de 2,5 años (RIQ 1,1-4,8 años); 578 (54%) fueron de sexo masculino. El tipo de complicación más frecuente fueron las infecciones secundarias de piel y partes blandas con 768 casos (72%), se registró 13 (1,4%) fallecidos. En conclusión, en el INSN se hospitalizan con mayor frecuencia casos de varicela complicada en niños menores de cinco años, con un tiempo de hospitalización corto y con una baja proporción de fallecidos, la mayoría de complicaciones siendo relacionadas con las infecciones secundarias de piel y partes blandas.

The objective of the study was to describe the clinical and epidemiological characteristics of complicated chickenpox cases seen at the National Institute of Children’s Health (INSN, Spanish acronym) of Peru from 2001 to 2011. A case series was collected, including a total of 1,073 children with complicated chickenpox. The median age was 2.5 years (IQR 1.1-4.8 years), of which 578 (54%) were male. The most frequent complications were secondary skin and soft tissue infections with 768 cases (72%). 13 deaths (1.4%) were recorded. In conclusion, the hospitalizations due to complicated chickenpox in the INSN included mostly children under five, with a short stay and a low proportion of deaths most complications being related to secondary skin and soft tissue infections.

Facial herpes zoster – case report / Herpes Zóster Facial–Relato de caso

Este artigo descreve um caso de zoster facial o qual afetou um paciente do sexo masculino de dezesseis anos de idade. Suas ulcerações comprometiam a hemiface direita não ultrapassando alinha média facial. Foram realizados a observação e o acompanhamento do paciente durante e após o tratamento. O caso foi acompanhado do aparecimento das lesões até o processo final decicatrização, onde o paciente retornou à sua condição de vida normal.A infecção por herpes zoster parece ser o resultado de um sistema imunológico enfraquecido e os pacientes portadores devem ser monitorados a fim de detectar possíveis sequelas ou doenças oportunistas não diagnosticadas.

This article describes a case of facial zoster which affected a sixteen-year-old male patient. His ulcerations involved the majority of the right hemiface not surpassing the facial midline. The observation of fallow-up of the patient during and after treatment was accomplished and the case was followed up from appearance of the lesion up the final healing process, where the patient had retumed to his normal life condition. Herpes zoster infection seems to be an outcome of a weakened immunologic system and patients must be monitored in order to detect possible sequels or undetected non-diagnosed diseases.

Vacinas contra a varicela em crianças e adultos para profilaxia pós-exposição / Vaccines against varicella in children and adults for post-exposure prophylaxis

Introdução: As vacinas com vírus vivo atenuado para a prevenção da varicela (catapora) foram demonstradas tanto em ensaios clínicos randomizados (ECR) como em programas de basepopulacional de imunização em países como os Estados Unidos.No entanto, muitos países não imunizam rotineiramente ascrianças contra a varicela, e as exposições continuam a ocorrer.Embora a doença seja geralmente leve, complicações como infecção bacteriana secundária, pneumonia e encefalite ocorrem em cerca de 1% dos casos, levando comumente à hospitalização. Autilização de vacina contra a varicela em pessoas que foram recentemente expostas ao vírus da varicela-zóster tem sido estudada como uma forma de profilaxia pós-exposição(PPE)

Costos directos de varicela complicada en una población pediátrica de Colombia / Direct costs of complicated chicken pox in a Colombian pediatric population

Objetivo Estimar los costos directos de varicela en una población pediátrica de Colombia. Método Se diseño un estudio de casos retrospectivo sobre todos los casos de varicela diagnosticados de 2005-2008 en el Hospital Infantil Napoleón Franco Pareja de Cartagena de Indias, Colombia. Fue utilizada la perspectiva del hospital. Se buscaron costos de atención, laboratorio, imagenología y medicamentos. El microcosteo se realizó en pesos colombianos del 2010. Se realizó un ajuste por inflación. Resultados La mediana de costos totales hospitalarios fue de $ 898 766 (Q1: $ 197 348; Q3: $ 1 195 262). La mediana de costo por día hospitalario fue de $ 221 777 (Q1: $ 97 027; Q3: $ 293 740). En menores de 1 año la mediana de costo fue de $ 980 742 (Q1: $ 905 708; Q3: $ 1 026 031). En pacientes de 5-12 años la mediana de costo fue de $ 105 833 (Q1: $ 39 568; Q3: $ 891 824). Conclusiones. Los resultados se asemejan con estudios previos sobre el tema (en Panamá, e incluso algunos países desarrollados), evidenciando un relativo alto costo de enfermedad por varicela en Colombia. Estos resultados aumentan la evidencia a favor de la vacunación, e invitan a decisores en salud en Colombia a considerar la introducción de la vacunación contra varicela.

Objective Estimating the cost of chicken pox in a Colombian pediatric population. Methodology This was a retrospective case study which searched for all diagnosed chicken pox cases in the Napoleón Franco Pareja children’s hospital (Cartagena, Colombia), during 2005-2008. The hospital’s records/perspective was used. Cost related to health personnel, lab, diagnostic images and drugs were searched. The micro-costing was made at Colombian peso prices for 2010. An adjustment was made for inflation. Results Mean hospital costs were $ 898,766 (Q1: $ 197,348; Q3: $ 1,195,262). Mean hospital cost per day was $ 221,777 (Q1: $ 97,027; Q3: $ 293,740). Mean cost <1 year-old patients was $ 980,742 (Q1: $ 905,708; Q3: $ 1,026,031). Mean cost was $ 105,833 in 5-12 year-old patients (Q1: $ 39,568; Q3: $ 891,824). Conclusions The results were similar to those of previous studies (in Panama and some developed countries) highlighting relatively high illness costs in Colombia. These results increase the evidence in favor of vaccination and invite Colombian public health officials to consider introducing a chicken pox vaccine into Colombia.

Absceso de psoas como complicación de varicela / Psoas abscess as a chicken pox complication

La varicela es la enfermedad exantemática más frecuente, sucurso suele ser autolimitado y benigno. Están descriptas variadascomplicaciones bacterianas debido a la disrupción de la piel como barrera defensiva por las características de suslesiones y a la inmunodepresión asociada.El absceso de psoas es una enfermedad poco frecuente y de difícil diagnóstico, con un cuadro clínico generalmente inespecífico.Presentamos el caso de una niña de 5 años, que, cursando el 5º día de varicela, consulta por convulsión febril de la cual se recupera sin síntomas neurológicos. Presenta impotencia funcional de miembro inferior izquierdo y dolor en región lumbar y glútea, que irradia a la cadera de dicho miembro con imposibilidad de deambular.El diagnóstico definitivo se realizó con tomografía axial computada (TAC) el día de ingreso.El germen aislado fue Staphylococcus meticilino-resistente (SAMR) de la comunidad.El tratamiento consistió en el drenaje quirúrgico y antibióticos endovenosos.

Caracterização epidemiológica dos casos de varicela em pacientes internados em um hospital universitário da cidade do Recife / Epidemiological characterization of varicella cases in patients of a university hospital located in Recife

A varicela é uma doença cosmopolita, com contagiosidade extremamente acentuada, causada pelo vírus Varicela - Zoster. Embora considerada uma doença benigna da infância, atualmente tem-se demonstrado uma crescente incidência de complicações severas com um alto potencial de morbi-mortalidade em crianças e adultos previamente saudáveis. O trabalho tem como objetivo caracterizar o perfil epidemiológico dos casos de varicela em pacientes internados em um hospital universitário da cidade do Recife. Trata-se de um estudo do tipo descritivo-exploratório com abordagem quantitativa, realizado no período de janeiro de 2004 a janeiro de 2005 em pacientes internados por varicela no Hospital Universitário Oswaldo Cruz da cidade do Recife. Observou-se que, do total de 255 pacientes internados por varicela, 53 por cento eram do sexo masculino; 77,3 por cento dos casos apresentaram como complicação predominante as infecções bacterianas secundárias da pele, sendo a celulite a mais freqüente, em 48,1 por cento dos casos; verificou-se que 2 por cento evoluíram a óbito; constatou-se na análise dos custos e benefícios que ocorreria uma economia de R$ 61.710,00 se a população em estudo fosse vacinada. A pesquisa apresenta dados que fundamentam a importância da redução no número de casos da doença, tendo em vista que existe a possibilidade de uma evolução não satisfatória e, inclusive, evolução ao óbito. Nesse sentido, esses achados poderão nortear os gestores de saúde na adoção de condutas preventivas e no planejamento das ações de saúde.

Varicella induced thrombocytopenia in adults

To describe the frequency and severity of thrombocytopenia associated with adult chickenpox patients admitted in the hospital. This was a hospital based descriptive study conducted from January 2005 to March 2008 at the Infectious Diseases Unit, Rashid Hospital Dubai, United Arab Emirates. The study was designed to record demographics, clinical information, hematological and biochemical changes observed in each patient. The data was entered into a structured proforma separately. Patients with history of chronic liver disease, immunocompromized status [HIV/Drugs], history of blood disorder, recent intake of drugs/conditions which can cause thrombocytopenia and active alcohol consumers were excluded from the study. Full blood count including platelet count was performed by an automated Beckman Coulter machine. To verify the hematological finding, the cases with low platelet count [thrombocytopenia] were subjected to peripheral smear examination. A total of 110 patients were recruited into the study. The mean age +/- SD of the patients under the study was 32.9 +/- 9.7 years and males outnumbred the females, 83.6%vs 16.3%. Forty six [41.8%] patients developed thrombocytopenia and their mean platelet count was 111.8 +/ -30.59x10[3] /ul [24-149x10[3] /ul]. High frequency of thrombocytopenia was observed in patients who also had associated varicella pneumonia, hepatic dysfunction and renal impairment. None of the patients with thrombocytopenia developed bleeding manifestations during the course of the disease. Platelet count returned to the reference range within 1-2 weeks of the treatment of varicella without platelet transfusion. Thrombocytopenia is frequently associated with chickenpox. The incidence of thrombocytopenia was observed higher in patients with the evidence of disseminated disease. Furthermore, low platelet count usually does not cause bleeding tendency and count improves with the treatment of varicelta

Pattern of varicella and associated complications in children in United Arab Emirates: 5-year descriptive study

The objective of this study was to characterize the epidemiology of varicella and varicella associated complications in Al-Ain, United Arab Emirates [UAE] during 2000-04. The annual number of reported cases varied from 373 to 790 per 100 000 population. Most [89%] occurred in children < 15 years old. Of 187 children requiring hospital admission, 50.3% had febrile illness due to secondary bacterial infection and 17.6% had neurological complications. The overall mortality rate among hospitalized children was 1.1%, all due to invasive group A Streptococcus. Varicella and associated complications in previously healthy children is becoming an important clinical and public health problem in the UAE