Varicella: sintomi, diagnosi e complicanze
Table of Contents
Cos’è la varicella?
La varicella è una malattia infettiva virale a elevata contagiosità, caratterizzata da eruzione vescicolosa, in genere benigna. La varicella si manifesta con esantema, febbre di modesta entità, faringodinia, tosse secca, cefalea e astemia. L’esantema inizia al volto e al cuoio capelluto e si estende rapidamente a tronco, addome e arti; raramente il palmo delle mani e la pianta dei piedi.
Eziologia
La varicella è provocata dal virusvaricellazoster (Vzv), della famiglia degli Herpes virus. Appartiene alla sottofamiglia Alphaherpesvirinae e, analogamente agli altri virus della famiglia Herpesviridae, ha la proprietà di replicare nel nucleo della cellula ospite in cui può inserirsi stabilmente nel corso della prima infezione per poi riattivarsi a distanza di tempo. E’ provvisto di DNA a doppio filamento. L’uomo è l’unico serbatoio noto di questo virus: la malattia si trasmette quindi soltanto da uomo a uomo.
Varicella, come si contrae
Il contagio è diretto per inalazione di goccioline di saliva da soggetti infetti che sono contagiosi da 24 ore prima della comparsa dell’esantema fino a 6 giorni dopo; qualche volta il virus è trasmesso da un paziente colpito daherpes zoster. La varicella è molto contagiosa e la maggior parte degli adulti l’hanno avuta. L’immunità e durevole. La varicella è grave nei soggetti immunodepressi e in particolare nei casi trattati con terapia immunosoppressiva. Il virus aggredisce lo strato spinoso della pelle dove provoca una degenerazione vacuolare delle cellule e la formazione di inclusioni intranucleari. Dopo la guarigione clinica della varicella, il virus migra lungo i nervi sensitivi e rimane latente nei linfonodi nervosi dove può essere riattivata dopo anni e provocare un herpes.
Sintomi della varicella
Il periodo di incubazioneè di 14-21 giorni. Dopo 24-36 ore, comparsa di una febbre moderata e di una eruzione cutanea prima maculare e poi in 24-48 ore vescicolare caratteristica su fondo rosso.
Esantema: l’eruzione è localizzata al tronco nelle forme più lievi; può essere generalizzata e colpire le mucose (enantema). Levescicoledi forma rotondeggiante oppure ovalare, didimensione compresa tra 2 e 5 mm, hanno un alone eritematoso alla base e presentano inizialmente contenuto limpido trasparente; dopo poche ore dalla comparsa assumono aspetto ombelicato e il loro contenuto diventa torbido, quindi si afflosciano e si rompono dando luogo alla formazione di croste brunastre.Si seccano in 2-3 giorni,e le piccole croste cascano verso il quinto giorno senza lasciare cicatrici salvo in caso che ilmalato si sia grattato.
L’eritema è accompagnato generalmente da altri sintomi:
- febbre di modesta entità
- mal di gola
- tosse secca
- cefalea
- astenia
- artromialgie
Varicella e gravidanza
La varicella contratta nel primo trimestre di gravidanzapuò essere causa di aborto o di importanti lesioni malformative (basso peso alla nascita, microftalmia, cataratta, ipoplasia degli arti, cicatrici cutanee, atrofia corticale e microcefalia).
La varicella contratta nel secondo e terzo trimestredà luogo a un’ infezione fetale inapparente che potrà essere all’origine di un episodio di herpes zoster in un bambino con anamnesi negativa per varicella.
Quando la quando la varicella si presenta nelle ultime settimane di gravidanza o qualche giorno dopo il partola trasmissione diaplacentare del virus può dare luogo a una varicella neonatale lieve o molto grave in relazione alla quantità di anticorpi trasmessi al feto. Se nella madre l’esantema compare da 6 a 15 giorni prima del parto, il neonato presenterà un quadro clinico lieve. Al contrario, se l’esantema si manifesta da 5 giorni prima a 2 giorni dopo il parto, la scarsa quantità di anticorpi trasmessi non sarà sufficiente ad impedire la disseminazione virale; si avrà quindi un quadro dipoliviscerite neonatalecon manifestazioni emorragiche sia cutanee sia mucose, compromissione di diversi organi (polmoni, fegato, rene, encefalo) e di una letalità del 30%.
Complicanze della varicella
Le complicanze si sviluppano in seguito a sovrainfezione batterica o all’azione diretto in diretta( immunomediata) del virus. Le sovrainfezioni batteriche interessano comunemente la cute e l’apparato respiratorio. Le infezioni streptococciche e stafilococciche comportano l’ impetiginizzazione delle lesioni: le vescicole acquistano un aspetto pustoloso più raramente ulcerato.
Nell’adulto immunodepresso:
- polmonite virale molto grave
- encefalite virale(molto rara)
- porpora trombocitopenica
- nefrite acuta (streptococco)
- setticemia da streptococco o stafilococco
- Nel bambino sottoposta a terapia immunosoppressiva o a corticoterapia prolungata, la varicella è molto grave.
A carico dell’ apparato respiratorio una complicanza da sovrainfezione batterica, da non sottovalutare, specialmente nei pazienti più piccoli, è labroncopolmonite.
Varicella, diagnosi
La diagnosi di varicella è essenzialmente clinica. L’esame al microscopio degli strisci delle cellule epiteliali prelevate a livello delle lesioni e colorate al Giemsa mostra delle inclusioni intranucleari. Si può coltivare e identificare il virus ma questi esami non hanno interesse pratico.
Prognosi
La prognosi è buona, salvo in caso di complicazioni, molto rare, nei pazienti immunodepressi.
La terapia
- Forme comuni:riposo a letto nel periodo febbrile; talco sulle lesioni cutanee per evitare il grattamento che può lasciare cicatrici indelebili (tagliare le unghie, mettere i guanti);antibioticiin caso di sovrainfezione batterica.
- Forme gravi:aciclovir, la cui somministrazione deve essere iniziata entro 24 ore dalla comparsa delle prime vescicole, determina l’attenuazione della sintomatologia e abbrevia il decorso della malattia. E’ indicato negli adolescenti e negli adulti, oltre che nei pazienti immunocompromessi o con complicanze.
Vaccino contro la varicella
L’infezione da VZV può essere prevenuta con il vaccino costituito da un virus vivo attenuato (ceppo Oka), che in alcuni paesi è raccomandato per tutti i bambini nel secondo anno di vita. La vaccinazione va effettuata con una sola dose ai bambini tra i 12 mesi e 12 anni di età e con due dosi dopo i 12 anni; come per gli altri vaccini vivi attenuati è controindicata negli individui con deficit della risposta immunitaria. Il Piano Nazionale Prevenzione vaccinale ha previsto l’introduzione universale di questa vaccinazione a partire dal 2015.
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