August 1997
WASHINGTON, D.C. — In assessing the evolution of the relationship between varicella and group A streptococcal (GAS) infections, three distinct eras can be identified: the pre-antibiotic era, the early antibiotic era and the late antibiotic era.
"The pre-antibiotic era extended from Heberden's original description of varicella in 1782 until 1945; the early antibiotic era lasted from 1945 to 1975; and the late antibiotic era began in 1976 and continues today," said Stanford T. Shulman, MD, at the recent Pediatric Academic Societies meeting held here.
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In addition to Heberden's description of typical varicella, he also recognized a malignant type of chickenpox characterized by continued fever and redder and larger pox lesions.
"Henoch in 1882 recognized the serious consequences of chickenpox only when combined with other infections. These reports closely followed Pasteur's discovery of streptococci and staphylococci between 1877 and 1880. Howard in 1883 described a 1-year-old with fatal gangrenous varicella lesions that exposed muscle; and Edwards in 1903 noted that varicella gangrenosa was due to streptococci and staphylococci," Shulman explained.
In a landmark pre-antibiotic era study, Bullowa and Wishik reviewed 2,534 varicella patients hospitalized at the Willard Parker Hospital for Contagious Diseases in New York City between 1929 and 1933. Infectious complications were experienced by 133 (5%) of these children. "This exceeded the sepsis rates in other classic infectious diseases," he said.
In New York at the same time, Rebecca Lancefield, MD, was developing her serologic grouping system that ultimately enabled the differentiation of group A from other hemolytic streptococci.
"Although antibiotics were not yet available, other therapies such as serum therapy were widely used with apparent benefit. From all of these reports, it was obvious that serious streptococcal complications of varicella were well-recognized during this era," he said.
In the early antibiotic era, which was the first 30 years after the introduction of penicillin, there were almost no published reports of GAS complications of varicella. "Therefore, one must conclude that serious streptococcal complications of varicella were very unusual during this period. This is very different from the late antibiotic era," he noted.
Beginning in the late 1970s, and particularly in the past 10 to 12 years, there have been increasing reports of GAS infections complicating varicella. These reports parallel an increase in severe pediatric and adult streptococcal infections not associated with varicella.
"Early in this period, streptococcal infections accounted for relatively few hospitalizations. However, in nine reports published since 1992, about 25% of such infections were related to varicella," he added.
The 1992-1993 Ontario surveillance data documented the rate of invasive GAS infections in children with varicella to be 4.4:100,000 each year and the relative risk of such infections in the two weeks after the onset of varicella to be 39.
"The resurgence of streptococcal complications of varicella has occurred despite continued universal sensitivity of GAS to b-lactam agents and no apparent increase in the severity of primary varicella. Rather, this likely reflects increased virulence of certain group A strains of particular serotypes as a direct consequence of pyrogenic exotoxin production, especially streptococcal pyrogenic exotoxin A. The possible contributing influence of other factors including nonsteroidal anti-inflammatory agents is under current investigation," he said.
According to Shulman, the resurgence of serious complications of varicella "highlights the wisdom of recommending widespread use of the varicella vaccine to prevent this kind of infection."
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