Neonatal varicella zoster transmission from mother, management in a resource-limited setting: A case report

Abstract

BACKGROUND

Neonatal varicella is a rare but potentially life-threatening condition resulting from vertical transmission of varicella-zoster virus from mother to newborn in the last 3 weeks of pregnancy or acquired after few days of delivery.

CASE SUMMARY

We present a case of a 15 days old male neonate who contracted varicella within the first two weeks of life, born to a mother with unvaccinated status and exposure to varicella zoster infection within family. Diagnosis was made clinically based on the characteristic rash all over the body and fever, despite the unavailability of gold standard diagnostic tests like polymerase chain reaction. In the absence of varicella-zoster immunoglobulin (VZIG), the neonate was successfully managed with intravenous acyclovir, antibiotics and supportive care. Prompt initiation of antiviral therapy and meticulous supportive care led to a favourable outcomes. This case demonstrates that: (1) Clinical diagnosis of neonatal varicella zoster can be made based on characteristic rash in the absence of gold standard diagnostic tests, facilitating timely management in resource-limited settings; (2) Intravenous acyclovir therapy, in combination with antibiotics and supportive care, is an effective treatment when VZIG is unavailable; and (3) Early recognition and prompt antiviral therapy is crucial in preventing complications and improving outcomes in affected newborns.

CONCLUSION

This case highlights the importance of clinical acumen in diagnosing neonatal varicella and the effectiveness of acyclovir therapy in resource-limited settings, where access to advanced diagnostic tests and specific immunoglobulins may be restricted.

Key Words: Neonatal varicella; Resource-limited setting; Vertical transmission; Clinical diagnosis; Intravenous acyclovir; Supportive care; Varicella-zoster immunoglobulin unavailability; Maternal infection; Management challenges; Case report

Core Tip: This case report highlights the critical management of neonatal varicella in a resource-limited setting where standard interventions like varicella-zoster immunoglobulin and polymerase chain reaction testing are unavailable. It demonstrates that a timely clinical diagnosis based on characteristic rash and maternal history, coupled with prompt intravenous acyclovir therapy and meticulous supportive care, can lead to a favourable outcome. The case underscores the importance of clinical acumen and accessible antiviral treatment as effective alternatives for managing this life-threatening condition when advanced resources are constrained.

INTRODUCTION

The varicella-zoster virus (VZV), which causes varicella, is a highly contagious infection that usually manifests in childhood as a self-limiting febrile illness with a distinctive vesicular rash. The virus can reactivate as herpes zoster later in life after establishing a lifelong latency in sensory ganglia following primary infection[1,2]. While varicella is typically mild in immunocompetent children, infection during pregnancy, especially around the time of delivery, can cause the newborn to have a serious and possibly fatal illness. Neonatal varicella is an uncommon but serious illness that arises when a mother contracts an infection in the latter stages of pregnancy, usually within five days prior to or two days following delivery. Because there is insufficient transplacental transfer of protective maternal antibodies during this brief peripartum window, the newborn is exposed to high viral loads without passive immunity. As a result, neonatal varicella acquired during this period is associated with a markedly increased risk of severe disseminated disease, including pneumonia, hepatitis, encephalitis, and mortality[3-5].

Transmission to the neonate may occur transplacentally, through direct contact with maternal lesions during delivery, or postnatally via respiratory droplets or contact with vesicular fluid. Clinical symptoms can range from a widespread vesiculopustular rash to quickly developing systemic involvement and usually appear within the first five to ten days of life. Because prompt initiation of antiviral therapy and immunoprophylaxis can greatly improve outcomes, early detection is crucial[6].

Neonatal varicella management is particularly difficult in low- and middle-income countries, where access to varicella-zoster immunoglobulin (VZIG) and confirmatory diagnostics like polymerase chain reaction (PCR) testing may be restricted or nonexistent. In these situations, clinicians frequently base their management choices on a thorough maternal history, distinctive clinical findings, and early empirical antiviral therapy. These constraints underscore the importance of clinical vigilance and context-appropriate management strategies in reducing neonatal morbidity and mortality.

CASE PRESENTATION

Chief complaints

A 15-day-old male neonate presented with fever and a generalized vesicular rash.

History of present illness

A 15-day-old male neonate, born at 39 weeks’ gestation via spontaneous vaginal delivery to a 27-year-old mother, presented to the outpatient department with fever and a generalized vesicular rash. The neonate was bottle-fed and had poor feeding, with frequent post-feed vomiting.

History of past illness

There was no history of birth complications, and the immediate postnatal period had been unremarkable.

Personal and family history

Maternal history revealed that the mother, who had not received varicella vaccination, developed a vesicular rash associated with mild systemic symptoms eight days prior to the neonate’s presentation, consistent with varicella infection. In addition, there was a documented history of varicella exposure within the household.

Physical examination

On admission, the neonate was hemodynamically stable but febrile. Physical examination revealed widespread vesicular lesions at varying stages of evolution, involving the trunk, face, scalp, and extremities (Figure 1). No signs of respiratory distress were observed. Chest examination demonstrated clear bilateral breath sounds without crepitations or wheeze. Abdominal examination showed a soft, non-tender abdomen without organomegaly, and bowel sounds were normal. Urine output and stool frequency were appropriate for age.

Figure 1 Physical examination revealed widespread vesicular lesions. A: Generalized vesiculopapular rash involving the trunk and extremities at the time of admission to the neonatal intensive care unit; B: Close-up view of the face and scalp demonstrating diffuse vesicular and erythematous lesions at varying stages of evolution.

Laboratory examinations

Laboratory evaluation demonstrated mild hepatic involvement, with a serum alanine aminotransferase level of 44 IU/L. Blood urea was within normal limits at 12 mg/dL, and serum creatinine was low-normal at 0.3 mg/dL, consistent with neonatal reference ranges. Hemoglobin level was mildly reduced at 11.2 g/dL, while the total leukocyte count was elevated at 13.2 × 10⁹/L, suggestive of an inflammatory response. C-reactive protein was also elevated at 21 mg/L.

A coagulation profile, including prothrombin time and activated partial thromboplastin time, was performed to assess coagulation status and monitor for potential complications; results were within normal neonatal reference ranges.

Imaging examinations

A chest radiograph showed no abnormalities (Figure 2).

Figure 2 Chest X-ray performed during follow-up.

MULTIDISCIPLINARY EXPERT CONSULTATION

Management followed a comprehensive and multidisciplinary approach.

FINAL DIAGNOSIS

Based on the characteristic rash, maternal history, and epidemiological exposure, a clinical diagnosis of neonatal varicella was made.

TREATMENT

Management followed a comprehensive and multidisciplinary approach. Given the diagnosis of neonatal varicella and the unavailability of VZIG, intravenous acyclovir was initiated promptly at a total daily dose of 60 mg, administered in three divided doses, to limit viral replication and reduce disease severity.

Empirical intravenous antibiotics were administered to prevent and treat potential secondary bacterial infections, consisting of vancomycin (60 mg three times daily) and cefotaxime (250 mg twice daily). Antipyretic therapy with paracetamol was provided on an as-needed basis for fever control.

Supportive care was emphasized. Due to poor oral intake, nasogastric feeding was initiated with small volumes (10 mL every two hours) and gradually advanced to full enteral feeds as tolerance improved. Intravenous fluid therapy was used to maintain hydration, beginning with a 20 mL/kg normal saline bolus followed by maintenance fluids at 13 mL/hour, which were gradually tapered as enteral feeding was established.

Nebulization with beclomethasone (0.25 mL) diluted in normal saline (2 mL) was administered twice daily for symptomatic respiratory support, although no significant respiratory compromise was observed.

OUTCOME AND FOLLOW-UP

During hospitalization, the clinical course was favorable. By the fourth day of admission, the vesicular lesions had progressed to crusting, accompanied by defervescence and improved feeding tolerance (Figure 3). No new lesions developed, and no systemic complications were observed.

Figure 3 Vesicular lesions had progressed to crusting. A: Progression of cutaneous involvement on the trunk and upper limb; B: Detailed view of truncal skin lesions illustrating extensive vesiculopapular eruptions.

By the sixth day of admission, the neonate was clinically stable and was discharged from the hospital. At follow-up on the eighth day post-discharge, the infant was feeding well without vomiting or reluctance. Physical examination was unremarkable, and a chest radiograph showed no abnormalities (Figure 2). The skin lesions had undergone near-complete resolution, with only minimal residual scarring noted (Figure 4). No late complications were observed.

Figure 4 Clinical appearance of the neonate at follow-up after completion of treatment.

DISCUSSION

Neonatal varicella is a high-stakes clinical condition resulting from the vertical transmission of the VZV. The severity of the infection is largely determined by the timing of maternal infection relative to delivery. Literature indicates that the most critical period for severe neonatal disease occurs when the maternal rash appears between five days before and two days after birth, as this window precludes the effective transplacental transfer of protective maternal immunoglobulin G antibodies[2,3]. In this case, the neonate presented on the 15^th day of life following maternal infection, a timeline that underscores the vulnerability of newborns during the first month of life[6].

A primary challenge highlighted in this report is the management of VZV in resource-constrained environments where molecular diagnostics, such as PCR, are unavailable. While PCR is the definitive gold standard for VZV detection, clinical diagnosis remains the cornerstone of management in many global settings[7]. The presence of pathognomonic vesiculopapular lesions at varying stages of evolution, coupled with a confirmed maternal history, allowed for rapid clinical identification. Recent studies emphasize that in settings lacking advanced laboratory infrastructure, clinicians must rely on these classical physical findings to initiate life-saving therapy without delay[3,8].

The management of this patient was notably complicated by the unavailability of VZIG, which is the standard of care for post-exposure prophylaxis. The novelty of this case lies in the successful use of high-dose intravenous acyclovir (60 mg/kg/day) as a primary therapeutic strategy. Recent evidence from 2024 supports the efficacy of early antiviral intervention as a vital alternative when VZIG is inaccessible, effectively preventing visceral dissemination and reducing mortality rates that can otherwise reach 30%[9,10].

Empirical broad-spectrum antibiotic therapy including vancomycin and a third-generation cephalosporin (cefotaxime) was initiated because bacterial sepsis could not be promptly excluded at presentation, a scenario commonly encountered in neonatal care where clinical signs overlap between viral infection and serious bacterial sepsis and definitive culture results may be delayed or unavailable. In our setting, local data demonstrate a high burden of neonatal sepsis with low blood culture positivity and frequent resistance to first-line antibiotics, making regimen selection challenging[11]. In addition, skin integrity loss in neonatal varicella predisposes patients to invasive infections from Staphylococcus aureus or group A Streptococcus, which are major drivers of morbidity[1,6]. The favorable outcome, marked by the near-complete resolution of lesions by the eighth day and clear follow-up imaging, demonstrates that meticulous supportive care including hydration and nutritional support combined with prompt antiviral therapy can overcome the absence of expensive biologics[1,10].

While the successful recovery of the neonate is encouraging, the lack of VZIG and PCR confirmation remains a significant limitation. This case serves as a critical reminder of the need for maternal vaccination and the development of simplified protocols for managing neonatal varicella in limited-resource settings. By emphasizing clinical acumen and accessible antiviral medications, healthcare providers can significantly improve outcomes for this vulnerable population[6,12].

CONCLUSION

This case highlights the challenges of diagnosing and managing neonatal varicella in resource-limited settings, emphasising the reliance on clinical acumen and supportive treatment. This case also addresses the significance of early diagnosis and treatment of neonatal varicella, particularly in resource-limited settings where access to specialised care may be challenging. Timely antiviral therapy, supportive care, and vigilant monitoring for complications can significantly improve neonatal outcomes.