Post-Varicella Complications in Children: Treatment Approach
The most critical post-varicella complications requiring immediate recognition and treatment in children are bacterial superinfections (particularly invasive Group A Streptococcus), neurologic complications (cerebellitis, encephalitis), and musculoskeletal infections, with treatment prioritizing early surgical intervention for invasive infections and antiviral therapy reserved for immunocompromised patients or severe complications. 1
Most Common Complications
The predominant post-varicella complications in otherwise healthy children include:
- Bacterial skin and soft tissue infections - the most frequent complication, occurring in 26% of hospitalized cases 2
- Neurologic complications - present in 61.3% of severe cases, with cerebellitis being most common (40.3%), followed by encephalitis (18.5%) 2
- Invasive bacterial infections - including pyomyositis, septic arthritis, osteomyelitis, and necrotizing fasciitis 1, 3, 4
- Pneumonia and central nervous system complications - the leading causes of varicella-related deaths 1
Critical Pathogen: Group A Streptococcus
Group A beta-hemolytic Streptococcus (GAS) is the dominant pathogen in severe post-varicella complications, accounting for 84% of bacterial infections requiring operative treatment. 4
- GAS causes the majority of osteomyelitis (5 of 7 cases), necrotizing fasciitis (3 of 5 cases), and all deep-tissue abscesses in post-varicella patients 4
- GAS infection increases the necessity for surgical intervention by 7.51-fold 5
- GAS is responsible for 15.1% of all severe complications and is linked to 50% of cases with defect healing 2
Treatment Algorithm by Complication Type
Bacterial Superinfections
For skin and soft tissue infections:
- Initiate empiric antibiotic coverage targeting GAS and Staphylococcus aureus 2, 4
- Maintain high suspicion for invasive disease if the child has limb or joint pain 3
- Obtain MRI imaging promptly when musculoskeletal involvement is suspected 3
For invasive infections (osteomyelitis, septic arthritis, necrotizing fasciitis):
- Immediate surgical consultation and intervention is mandatory - these are life- and limb-threatening emergencies 3, 4
- Surgical debridement is required for necrotizing fasciitis, deep abscesses, and most cases of osteomyelitis 3, 4
- Prolonged intravenous antibiotic therapy following surgical management 3
Neurologic Complications
- Cerebellitis - typically self-limited; supportive care is primary treatment 2
- Encephalitis - consider antiviral therapy with intravenous acyclovir, though evidence is limited in immunocompetent children 6
- Post-varicella arteriopathy - requires neurologic consultation and consideration of antiviral therapy even months after primary infection 6
Antiviral Therapy Indications
Acyclovir is NOT routinely indicated for uncomplicated varicella in healthy children. 7
Acyclovir should be considered for:
- Immunocompromised patients 7, 8
- Severe complications such as encephalitis, pneumonia, or disseminated disease 6
- Dosing: 800 mg orally 4 times daily for 5 days in children >40 kg; 20 mg/kg orally 4 times daily for children 2 years and older weighing <40 kg 8
- Intravenous acyclovir is indicated for varicella-zoster infections in immunocompromised patients 8
Critical Pitfall: Ibuprofen Use
Avoid ibuprofen in children with varicella - it increases the risk of post-treatment complications by 4.07-fold and increases surgical intervention necessity by 2.87-fold. 5
- Use acetaminophen (non-salicylate) for fever control instead 5
- Avoid salicylates for 6 weeks after varicella vaccination due to Reye syndrome risk 1
Age-Specific Risk Patterns
- Infectious complications occur predominantly in children under 4 years of age 2
- Neurologic complications occur more frequently in older children (4-16 years) 2
- Infants under 1 year are 6 times more likely to be hospitalized than children aged 5-9 years 1
Outcomes and Prognosis
- 69% of hospitalized children with bacterial complications achieve full recovery 5
- 29% have transient complications 5
- 6.7% experience long-term sequelae, with infectious complications (particularly GAS) contributing disproportionately to chronic deficits 2
- Mortality is rare in immunocompetent children but occurs primarily from pneumonia, CNS complications, and invasive bacterial infections 1
Post-Exposure Prophylaxis for Contacts
- Varicella vaccine administered within 3 days of exposure is >90% effective in preventing disease 1
- Vaccine given within 5 days is 70% effective in preventing disease and 100% effective in modifying severe disease 1
- Varicella-zoster immune globulin (VariZIG) should be considered for high-risk exposed individuals without immunity 7
Key Clinical Red Flags
Watch for these warning signs requiring immediate evaluation: