Treatment of Chickenpox in Primary Immunodeficiency, Immunosuppressive Chemotherapy, or Radiotherapy

Patients in this population are at risk of severe varicella-zoster virus (VZV) infection and should receive antiviral therapy as soon as possible.

At-Risk Population

This protocol applies when chickenpox occurs in patients with any of the following:

Primary immunodeficiency (e.g. Severe Combined Immunodeficiency, Wiskott-Aldrich syndrome)
Immunosuppressive chemotherapy or radiotherapy for malignant disease within the last 6 months
Bone marrow transplantation within the last 12 months (or longer if graft-versus-host disease is present)
Solid organ transplant on immunosuppressive therapy
Systemic steroids (more than 40 mg prednisolone/day for more than 1 week) within the last 3 months
Other immunomodulatory drugs (such as azathioprine, cyclosporine, methotrexate, cyclophosphamide, or cytokine inhibitors)
HIV infection, particularly with a low CD4 count

Clinical Goal

Settling of temperature, with close monitoring for complications throughout the admission.

Treatment Approach (Partial Overview)

Early hospital admission to an isolation bed is recommended. Intravenous Aciclovir is the cornerstone of antiviral management in this immunocompromised population, with a transition to oral therapy as soon as clinical improvement allows.

Complete dosing, monitoring parameters, and escalation guidance are available in the full structured protocol below.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1016/j.jinf.2008.03.004

Patients in the categories shown in Table 2 should be considered as being at risk of severe VZV infection, and should receive antiviral therapy as soon as possible.

Patients with severe primary immunodeficiency such as Severe Combined Immunodeficiency (SCID) or Wiskotte Aldrich syndrome.

All patients receiving immunosuppressive chemotherapy or radiotherapy for malignant disease, up to 6 months after completion of treatment.

All patients on immunosuppressive therapy following a solid organ transplant.

All patients who have undergone bone marrow transplantation, up to 12 months after completing all immunosuppressive therapy, or longer if graft versus host disease has occurred.

Patients receiving other immunomodulatory drugs such as azathioprine, cyclosporine, methotrexate, cyclophosphamide and the cytokine inhibitors, and/or chronic low dose steroid therapy.

Patients with HIV infection, particularly if the CD4 count is less than 200 cells/mm3.

Early assessment in hospital is recommended, as parenteral treatment is most appropriate to prevent complications.

Aciclovir at a dose of 10 mg/kg intravenously every 8 h should be used for those who have or are at risk of severe disease.

Two weeks therapy may be appropriate in severe disease or in the immunocompromised, for whom intravenous therapy is usually recommended, although with rapid improvement an early switch to oral therapy may be considered.

Switch to oral therapy as soon as possible.

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