varicella pneumonia

Chickenpox
	Male with varicella disease
Classification and external resources
Specialty	Infectious disease
ICD-10	B01
ICD-9-CM	052
DiseasesDB	29118
MedlinePlus	001592
eMedicine	ped/2385 derm/74, emerg/367
Patient UK	Chickenpox
MeSH	C02.256.466.175
	[edit on Wikidata]

WordNet

respiratory disease characterized by inflammation of the lung parenchyma (excluding the bronchi) with congestion caused by viruses or bacteria or irritants

PrepTutorEJDIC

肺炎

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2016/01/23 14:38:07」(JST)

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Chickenpox, also known as varicella, is a highly contagious disease caused by the initial infection with varicella zoster virus (VZV).^[1] The disease results in a characteristic skin rash that forms small, itchy blisters, which eventually scab over.^[2] It usually starts on the chest, back, and face then spreads to the rest of the body.^[2] Other symptoms may include fever, feeling tired, and headaches.^[2] Symptoms usually last five to ten days.^[2] Complications may occasionally include pneumonia, inflammation of the brain, or bacterial infections of the skin among others.^[3] The disease is often more severe in adults than children.^[4] Symptoms begin ten to twenty one days after exposure to the virus.^[5]

Chickenpox is an airborne disease which spreads easily through the coughs and sneezes of an infected person.^[5] It may be spread from one to two days before the rash appears until all lesions have crusted over.^[5] It may also spread through contact with the blisters.^[5] Those with shingles may spread chickenpox to those who are not immune through contact with the blisters.^[5] The disease can usually be diagnosed based on the presenting symptom;^[6] however, in unusual cases may be confirmed by polymerase chain reaction (PCR) testing of the blister fluid or scabs.^[4] Testing for antibodies may be done to determine if a person is or is not immune.^[4] People usually only get the disease once.^[5]

The varicella vaccine has resulted in a decrease in the number of cases and complications from the disease.^[7] It protects about 70 to 90 percent of people from disease with a greater benefit for severe disease.^[4] Routine immunization of children is recommended in many countries.^[8] Immunization within three days of exposure may improve outcomes in children.^[9] Treatment of those infected may include calamine lotion to help with itching, keeping the fingernails short to decrease injury from scratching, and the use of paracetamol (acetaminophen) to help with fevers.^[5] For those at increased risk of complications antiviral medication such as aciclovir are recommended.^[5]

Chickenpox occurs in all parts of the world.^[4] Before routine immunization the number of cases occurring each year was similar to the number of people born.^[4] Since immunization the number of infections in the United States has decreased nearly 90%.^[4] In 2013 chickenpox resulted in 7,000 deaths globally – down from 8,900 in 1990.^[10] Death occurs in about 1 per 60,000 cases.^[4] Chickenpox was not separated from smallpox until the late 19th century.^[4] In 1888 its connection to shingles was determined.^[4] The first documented use of the term chicken pox was in 1658.^[11] Various explanations have been suggested for the use of "chicken" in the name, one being the relative mildness of the disease.^[11]

Signs and symptoms

A single blister, typical during the early stages of the rash

The early (prodromal) symptoms in adolescents and adults are nausea, loss of appetite, aching muscles, and headache. This is followed by the characteristic rash or oral sores, malaise, and a low-grade fever that signal the presence of the disease. Oral manifestations of the disease (enanthem) not uncommonly may precede the external rash (exanthem). In children the illness is not usually preceded by prodromal symptoms, and the first sign is the rash or the spots in the oral cavity. The rash begins as small red dots on the face, scalp, torso, upper arms and legs; progressing over 10–12 hours to small bumps, blisters and pustules; followed by umbilication and the formation of scabs.^[12]^[13]

At the blister stage, intense itching is usually present. Blisters may also occur on the palms, soles, and genital area. Commonly, visible evidence of the disease develops in the oral cavity and tonsil areas in the form of small ulcers which can be painful or itchy or both; this enanthem (internal rash) can precede the exanthem (external rash) by 1 to 3 days or can be concurrent. These symptoms of chickenpox appear 10 to 21 days after exposure to a contagious person. Adults may have a more widespread rash and longer fever, and they are more likely to experience complications, such as varicella pneumonia.^[12]

Because watery nasal discharge containing live virus usually precedes both exanthem (external rash) and enanthem (oral ulcers) by 1 to 2 days, the infected person actually becomes contagious one to two days before recognition of the disease. Contagiousness persists until all vesicular lesions have become dry crusts (scabs), which usually entails four or five days, by which time nasal shedding of live virus ceases.

The condition usually resolves by itself within a couple of weeks.^[14] The rash may, however, last for up to one month, although the infectious stage does not last longer than a week or two.^{[citation needed]}

Chickenpox is rarely fatal, although it is generally more severe in adult men than in women or children. Non-immune pregnant women and those with a suppressed immune system are at highest risk of serious complications. Arterial ischemic stroke (AIS) associated with chickenpox in the previous year accounts for nearly one third of childhood AIS.^[15] The most common late complication of chickenpox is shingles (herpes zoster), caused by reactivation of the varicella zoster virus decades after the initial, often childhood, chickenpox infection.

The back of a 30-year-old male after five days of the rash
A 3-year-old girl with a chickenpox rash on her torso
An Indian child with chickenpox at an orphanage in Howrah
Lower leg of a child with chickenpox

Pregnancy and neonates

During pregnancy the dangers to the fetus associated with a primary VZV infection are greater in the first six months. In the third trimester, the mother is more likely to have severe symptoms.^[16] For pregnant women, antibodies produced as a result of immunization or previous infection are transferred via the placenta to the fetus.^[17] Women who are immune to chickenpox cannot become infected and do not need to be concerned about it for themselves or their infant during pregnancy.^[18]

Varicella infection in pregnant women could lead to spread via the placenta and infection of the fetus. If infection occurs during the first 28 weeks of gestation, this can lead to fetal varicella syndrome (also known as congenital varicella syndrome).^[19] Effects on the fetus can range in severity from underdeveloped toes and fingers to severe anal and bladder malformation. Possible problems include:

Damage to brain: encephalitis,^[20] microcephaly, hydrocephaly,^[21] aplasia of brain
Damage to the eye: optic stalk, optic cup, and lens vesicles, microphthalmia, cataracts, chorioretinitis, optic atrophy
Other neurological disorder: damage to cervical and lumbosacral spinal cord, motor/sensory deficits, absent deep tendon reflexes, anisocoria/Horner's syndrome
Damage to body: hypoplasia of upper/lower extremities, anal and bladder sphincter dysfunction
Skin disorders: (cicatricial) skin lesions, hypopigmentation

Infection late in gestation or immediately following birth is referred to as "neonatal varicella".^[22] Maternal infection is associated with premature delivery. The risk of the baby developing the disease is greatest following exposure to infection in the period 7 days before delivery and up to 8 days following the birth. The baby may also be exposed to the virus via infectious siblings or other contacts, but this is of less concern if the mother is immune. Newborns who develop symptoms are at a high risk of pneumonia and other serious complications of the disease.^[23]

Diagnosis

Chickenpox.

The diagnosis of chickenpox is primarily based on the signs and symptom, with typical early symptoms followed by a characteristic rash. Confirmation of the diagnosis is by examination of the fluid within the vesicles of the rash, or by testing blood for evidence of an acute immunologic response.

Vesicular fluid can be examined with a Tzanck smear, or better by testing for direct fluorescent antibody. The fluid can also be "cultured", whereby attempts are made to grow the virus from a fluid sample. Blood tests can be used to identify a response to acute infection (IgM) or previous infection and subsequent immunity (IgG).^[24]

Prenatal diagnosis of fetal varicella infection can be performed using ultrasound, though a delay of 5 weeks following primary maternal infection is advised. A PCR (DNA) test of the mother's amniotic fluid can also be performed, though the risk of spontaneous abortion due to the amniocentesis procedure is higher than the risk of the baby's developing fetal varicella syndrome.^[23]

Pathophysiology

Exposure to VZV in a healthy child initiates the production of host immunoglobulin G (IgG), immunoglobulin M (IgM), and immunoglobulin A (IgA) antibodies; IgG antibodies persist for life and confer immunity. Cell-mediated immune responses are also important in limiting the scope and the duration of primary varicella infection. After primary infection, VZV is hypothesized to spread from mucosal and epidermal lesions to local sensory nerves. VZV then remains latent in the dorsal ganglion cells of the sensory nerves. Reactivation of VZV results in the clinically distinct syndrome of herpes zoster (i.e., shingles), postherpetic neuralgia,^[25] and sometimes Ramsay Hunt syndrome type II.^[26] Varicella zoster can affect the arteries in the neck and head, producing stroke, either during childhood, or after a latency period of many years.^[27]

Shingles

After a chickenpox infection, the virus remains dormant in the body's nerve tissues. The immune system keeps the virus at bay, but later in life, usually in an adult, it can be reactivated and cause a different form of the viral infection called shingles (also known as herpes zoster).^[28] The United States Advisory Committee on Immunization Practices (ACIP) suggests that every adult over the age of 60 years get the herpes zoster vaccine.^[29]

Shingles affects one in five adults infected with chickenpox as children, especially those who are immune suppressed, particularly from cancer, HIV, or other conditions. Stress can bring on shingles as well, although scientists are still researching the connection.^[30] Shingles are most commonly found in adults over the age of 60 who were diagnosed with chickenpox when they were under the age of 1.^[31]

Prevention

Hygiene measures

The spread of chickenpox can be prevented by isolating affected individuals. Contagion is by exposure to respiratory droplets, or direct contact with lesions, within a period lasting from three days before the onset of the rash, to four days after the onset of the rash.^[32] The chickenpox virus is susceptible to disinfectants, notably chlorine bleach (i.e., sodium hypochlorite). Like all enveloped viruses, it is sensitive to desiccation, heat and detergents.

Vaccine

The varicella vaccine is recommended in many countries.^[8] Some countries require the varicella vaccination or an exemption before entering elementary school. A second dose is recommended five years after the initial immunization.^[33] A vaccinated person is likely to have a milder case of chickenpox if they become infected.^[34] Immunization within three days of exposure may improve outcomes in children.^[9]

It is part of the routine immunization schedule in the US.^[35] Some European countries include it as part of universal vaccinations in children,^[36] but not all countries provide the vaccine due to its cost.^[8] In the UK as of 2014, the vaccine is only recommended in people who are particularly vulnerable to chickenpox.^[37]

Treatment

Treatment mainly consists of easing the symptoms. As a protective measure, people are usually required to stay at home while they are infectious to avoid spreading the disease to others. Cutting the nails short or wearing gloves may prevent scratching and minimize the risk of secondary infections.

Although there have been no formal clinical studies evaluating the effectiveness of topical application of calamine lotion (a topical barrier preparation containing zinc oxide, and one of the most commonly used interventions), it has an excellent safety profile.^[38] It is important to maintain good hygiene and daily cleaning of skin with warm water to avoid secondary bacterial infection.^[39] Scratching may also increase the risk of secondary infection.^[40]

Paracetamol (acetaminophen) but not aspirin may be used to reduce fever. Aspirin use by someone with chickenpox may cause the serious, sometimes fatal disease of the liver and brain, Reye syndrome. People at risk of developing severe complications who have had significant exposure to the virus may be given intra-muscular varicella zoster immune globulin (VZIG), a preparation containing high titres of antibodies to varicella zoster virus, to ward off the disease.^[41]^[42]

Antivirals are sometimes used.^[43]^[44]

Children

If oral acyclovir is started within 24 hours of rash onset, it decreases symptoms by one day but has no effect on complication rates.^[45]^[46] Use of acyclovir therefore is not currently recommended for individuals with normal immune function. Children younger than 12 years old and older than one month are not meant to receive antiviral medication unless they have another medical condition which puts them at risk of developing complications.^[47]

Treatment of chickenpox in children is aimed at symptoms while the immune system deals with the virus. With children younger than 12 years, cutting nails and keeping them clean is an important part of treatment as they are more likely to scratch their blisters more deeply than adults.^[48]

Aspirin is highly contraindicated in children younger than 16 years, as it has been related to Reye's syndrome.^[49]

Adults

Infection in otherwise healthy adults tends to be more severe.^[50] Treatment with antiviral drugs (e.g. acyclovir or valacyclovir) is generally advised, as long as it is started within 24–48 hours from rash onset.^[47] Remedies to ease the symptoms of chickenpox in adults are basically the same as those used for children. Adults are more often prescribed antiviral medication, as it is effective in reducing the severity of the condition and the likelihood of developing complications. Antiviral medicines do not kill the virus but stop it from multiplying. Adults are advised to increase water intake to reduce dehydration and to relieve headaches. Painkillers such as paracetamol (acetaminophen) are recommended, as they are effective in relieving itching and other symptoms such as fever or pains. Antihistamines relieve itching and may be used in cases where the itching prevents sleep, because they are also sedative. As with children, antiviral medication is considered more useful for those adults who are more prone to develop complications. These include pregnant women or people who have a weakened immune system.^[51]

Sorivudine, a nucleoside analogue, has been reported to be effective in the treatment of primary varicella in healthy adults (case reports only), but large-scale clinical trials are still needed to demonstrate its efficacy.^[52]

After recovering from chickenpox, it is recommended by doctors that adults take one injection of VZV immune globulin and one injection of varicella vaccine or herpes zoster vaccine.^{[citation needed]}

Prognosis

The duration of the visible blistering caused by varicella zoster virus varies in children usually from 4 to 7 days, and the appearance of new blisters begins to subside after the fifth day. Chickenpox infection is milder in young children, and symptomatic treatment, with sodium bicarbonate baths or antihistamine medication may ease itching. It is recommended to keep new infants from birth up to age 6 months away from an infected person for 10 to 21 days because their immune systems are not developed enough to handle the stress it can bring on.^[53] Paracetamol (acetaminophen) is widely used to reduce fever. Aspirin, or products containing aspirin, should not be given to children with chickenpox, as it can cause Reye's Syndrome.^[54]

In adults, the disease is more severe,^[55] though the incidence is much less common. Infection in adults is associated with greater morbidity and mortality due to pneumonia (either direct viral pneumonia or secondary bacterial pneumonia),^[56] bronchitis (either viral bronchitis or secondary bacterial bronchitis),^[56] hepatitis,^[57] and encephalitis.^[58] In particular, up to 10% of pregnant women with chickenpox develop pneumonia, the severity of which increases with onset later in gestation. In England and Wales, 75% of deaths due to chickenpox are in adults.^[23] Inflammation of the brain, or encephalitis, can occur in immunocompromised individuals, although the risk is higher with herpes zoster.^[59] Necrotizing fasciitis is also a rare complication.^[60]

Varicella can be lethal to adults with impaired immunity. The number of people in this high-risk group has increased, due to the HIV epidemic and the increased use of immunosuppressive therapies.^[61] Varicella is a particular problem in hospitals, when there are patients with immune systems weakened by drugs (e.g., high-dose steroids) or HIV.^[62]

Secondary bacterial infection of skin lesions, manifesting as impetigo, cellulitis, and erysipelas, is the most common complication in healthy children. Disseminated primary varicella infection usually seen in the immunocompromised may have high morbidity. Ninety percent of cases of varicella pneumonia occur in the adult population. Rarer complications of disseminated chickenpox include myocarditis, hepatitis, and glomerulonephritis.^[63]

Hemorrhagic complications are more common in the immunocompromised or immunosuppressed populations, although healthy children and adults have been affected. Five major clinical syndromes have been described: febrile purpura, malignant chickenpox with purpura, postinfectious purpura, purpura fulminans, and anaphylactoid purpura. These syndromes have variable courses, with febrile purpura being the most benign of the syndromes and having an uncomplicated outcome. In contrast, malignant chickenpox with purpura is a grave clinical condition that has a mortality rate of greater than 70%. The cause of these hemorrhagic chickenpox syndromes is not known.^[63]

Epidemiology

Primary varicella occurs in all countries worldwide. In 2013 the disease resulted in 7,000 deaths – down from 8,900 in 1990.^[10]

In temperate countries, chickenpox is primarily a disease of children, with most cases occurring during the winter and spring, most likely due to school contact. It is one of the classic diseases of childhood, with the highest prevalence in the 4– 10-year-old age group. Like rubella, it is uncommon in preschool children. Varicella is highly communicable, with an infection rate of 90% in close contacts. In temperate countries, most people become infected before adulthood, and 10% of young adults remain susceptible.

In the tropics, chickenpox often occurs in older people and may cause more serious disease.^[64] In adults, the pock marks are darker and the scars more prominent than in children.^[65]

In the United States, the Centers for Disease Control and Prevention (CDC) does not require state health departments to report infections of chicken pox, and only 31 states currently volunteer this information.^[66] However, in a 2013 study conducted by the social media disease surveillance tool called Sickweather, anecdotal reports of chickenpox infections on Facebook and Twitter were used to measure and rank states with the most infections per capita, with Maryland, Tennessee and Illinois in the top three.^[67]

Etymology

Why the term was used is not clear but it may be due to it being a relatively mild disease.^[11] It has been said to be derived from chickpeas, based on resemblance of the vesicles to chickpeas,^[11]^[68]^[69] or to come from the rash resembling chicken pecks.^[69] Other suggestions include the designation chicken for a child (i.e., literally 'child pox'), a corruption of itching-pox,^[68]^[70] or the idea that the disease may have originated in chickens.^[71] Samuel Johnson explained the designation as "from its being of no very great danger."^[72]

Society and culture

Some parents believe that it is better for children to contract chickenpox than to get the vaccine, and they deliberately expose their children to the virus, sometimes by taking them to "chickenpox parties." Doctors counter that children are safer getting the vaccine, which is a weakened form of the virus, than getting the disease, which can be fatal.^[73]

Other animals

Humans are the only known animal that the disease affects naturally.^[4] However, chickenpox has been caused in other primates, including chimpanzees^[74] and gorillas.^[75]

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^ "Is Necrotizing Fasciitis a complication of Chickenpox of Cutaneous Vasculitis?". atmedstu.com. Retrieved 18 January 2008.
^ Strangfeld A, Listing J, Herzer P, Liebhaber A, Rockwitz K, Richter C, Zink A (February 2009). "Risk of herpes zoster in patients with rheumatoid arthritis treated with anti-TNF-alpha agents". JAMA 301 (7): 737–44. doi:10.1001/jama.2009.146. PMID 19224750.
^ Weller TH (1997). "Varicella-herpes zoster virus". In Evans AS, Kaslow RA. Viral Infections of Humans: Epidemiology and Control. Plenum Press. pp. 865–92. ISBN 978-0-306-44855-3.
^ ^a ^b Chicken Pox Complications
^ Wharton M (1996). "The epidemiology of varicella-zoster virus infections". Infect Dis Clin North Am 10 (3): 571–81. doi:10.1016/S0891-5520(05)70313-5. PMID 8856352.
^ "Epidemiology of Varicella Zoster Virus Infection, Epidemiology of VZV Infection, Epidemiology of Chicken Pox, Epidemiology of Shingles". Retrieved 22 April 2008.
^ "Georgia ranks 10th for social media admissions of chickenpox". Retrieved 13 June 2013.
^ "Chickenpox in the USA". Retrieved 12 June 2013.
^ ^a ^b Belshe, Robert B. (1984). Textbook of human virology (2nd ed.). Littleton MA: PSG. p. 829. ISBN 0-88416-458-6.
^ ^a ^b Teri Shors (2011). "Herpesviruses: Varicella Zoster Virus (VZV)". Understanding Viruses (2nd ed.). Jones & Bartlett. p. 459. ISBN 978-0-7637-8553-6.
^ Pattison, John; Zuckerman, Arie J.; Banatvala, J.E. (1994). Principles and practice of clinical virology (3rd ed.). Wiley. p. 37. ISBN 0-471-93106-3.
^ Chicken-pox is recorded in Oxford English Dictionary 2nd ed. since 1684; the OED records several suggested etymologies
^ Johnson, Samuel (1839). Dictionary of the English language. London: Williamson. p. 195.
^ "Chicken Pox parties do more harm than good, says doctor". KSLA News 12 Shreveport, Louisiana News Weather & Sports.
^ Cohen JI, Moskal T, Shapiro M, Purcell RH (December 1996). "Varicella in Chimpanzees". Journal of Medical Virology 50 (4): 289–92. doi:10.1002/(SICI)1096-9071(199612)50:4<289::AID-JMV2>3.0.CO;2-4. PMID 8950684.
^ Myers MG, Kramer LW, Stanberry LR (December 1987). "Varicella in a gorilla". Journal of Medical Virology 23 (4): 317–22. doi:10.1002/jmv.1890230403. PMID 2826674.

External links

	Medicine portal
	Viruses portal

Chickenpox at DMOZ
"Prevention of Varicella: Recommendations of the Advisory Committee on Immunization Practices (ACIP)". Centers for Disease Control and Prevention (CDC). 12 July 1996. Retrieved 18 May 2013.
"Management of Varicella Zoster Virus (VZV) Infections" (PDF). Federal Bureau of Prisons: Clinical Practice Guideline. December 2011. Retrieved 18 May 2013.
John W. Gnann Jr. (2007). "Chapter 65 Antiviral therapy of varicella-zoster virus infections". PMID 21348091.
Sarah McSweeney-Ryan; Megan Sandel. "The Health Care of Homeless Persons - Part I - Varicella (Chickenpox" (PDF). Boston Health Care for the Homeless Program. Retrieved 18 May 2013.

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

1. 水痘帯状疱疹ウイルス感染の臨床的特徴：水痘 clinical features of varicella zoster virus infection chickenpox
2. 水痘帯状疱疹ウイルス感染の治療：水痘 treatment of varicella zoster virus infection chickenpox
3. 免疫不全患者における肺感染症 pulmonary infections in immunocompromised patients
4. アシクロビル：概要 acyclovir an overview
5. 成人における市中肺炎の疫学、病因、および微生物学 epidemiology pathogenesis and microbiology of community acquired pneumonia in adults

English Journal

When should clinicians suspect group A streptococcus empyema in children? A multicentre case-control study in French tertiary care centres.

Bellulo S1, Sommet J2, Lévy C3, Gillet Y4, Hees L4, Lorrot M5, Gras-Le-Guen C6, Craiu I7, Dubos F8, Minodier P9, Biscardi S10, Dommergues MA11, Béchet S3, Bidet P12, Alberti C13, Cohen R14, Faye A5; French Pediatric Infectious Diseases Study Group (GPIP).
Archives of disease in childhood.Arch Dis Child.2016 Apr 12. pii: archdischild-2015-309831. doi: 10.1136/archdischild-2015-309831. [Epub ahead of print]
BACKGROUND: The incidence of invasive group A streptococcus (GAS) infections is increasing worldwide, whereas there has been a dramatic decrease in pneumococcal invasive diseases. Few data describing GAS pleural empyema in children are available.OBJECTIVE: To describe the clinical and microbiologica
PMID 27073159

LGBT health and vaccinations: Findings from a community health survey of Lexington-Fayette County, Kentucky, USA.

Jones J1, Poole A2, Lasley-Bibbs V3, Johnson M4.
Vaccine.Vaccine.2016 Apr 7;34(16):1909-14. doi: 10.1016/j.vaccine.2016.02.054. Epub 2016 Feb 28.
Data on adult immunization coverage at the state level and for LGBT Americans in particular are sparse. This study reports the results of a 2012 Lexington-Fayette County, Kentucky, community health assessment's results asking about eight adult vaccinations among 218 lesbian, gay, bisexual, and trans
PMID 26930365

Using Computerized Physician Order Entry to Ensure Appropriate Vaccination of Patients with Inflammatory Bowel Disease.

Karr JR1, Lu JJ2, Smith RB1, Thomas AC1.
The Ochsner journal.Ochsner J.2016 Spring;16(1):90-5.
BACKGROUND: Inflammatory bowel disease (IBD) is a disorder in which an aberrant immune response in a genetically susceptible host, with influences from environmental factors, leads to intestinal inflammation. Vaccines against influenza and pneumococcal pneumonia are indicated for all patients with I
PMID 27046413

Japanese Journal

症例小細胞肺癌・間質性肺炎の治療中に播種性水痘を発症し死亡した1例

日本呼吸器学会誌 = Annals of the Japanese Respiratory Society 4(5), 403-407, 2015-09-10
NAID 40020592935

症例報告アシクロビル投与を行った水痘合併妊娠の1例 (第20巻記念号)

高知県医師会医学雑誌 = Journal of Kochi Medical Association 20(1), 217-221, 2015
NAID 40020428253

Related Pictures

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[autogenerated1-63] Chicken Pox Complications

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[Shors-69] Teri Shors (2011). "Herpesviruses: Varicella Zoster Virus (VZV)". Understanding Viruses (2nd ed.). Jones & Bartlett. p. 459. ISBN 978-0-7637-8553-6.

[70] Pattison, John; Zuckerman, Arie J.; Banatvala, J.E. (1994). Principles and practice of clinical virology (3rd ed.). Wiley. p. 37. ISBN 0-471-93106-3.

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[72] Johnson, Samuel (1839). Dictionary of the English language. London: Williamson. p. 195.

[73] "Chicken Pox parties do more harm than good, says doctor". KSLA News 12 Shreveport, Louisiana News Weather & Sports.

[74] Cohen JI, Moskal T, Shapiro M, Purcell RH (December 1996). "Varicella in Chimpanzees". Journal of Medical Virology 50 (4): 289–92. doi:10.1002/(SICI)1096-9071(199612)50:4<289::AID-JMV2>3.0.CO;2-4. PMID 8950684.

[75] Myers MG, Kramer LW, Stanberry LR (December 1987). "Varicella in a gorilla". Journal of Medical Virology 23 (4): 317–22. doi:10.1002/jmv.1890230403. PMID 2826674.

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