Varicella-zoster virus (VZV), the cause of varicella and zoster, is divided into five major clades and four provisional clades, the latter of which have been rarely reported worldwide to date. We present a varicella outbreak by the provisional clade VI within an Indian couple in Germany returning from a trip to Amsterdam. To the best of our knowledge, this is the first case of varicella by the VZV clade VI described in Germany, but the disease was acquired in The Netherlands.
Varicella-zoster virus (VZV), a member of the genus
A married couple from India, a 32-year-old man and a 25-year-old woman, was admitted to the dermatologic clinic in July 2010 since both had developed varicella. The woman was pregnant at week 34 of gestation. In both patients, an immunodeficiency was not known. One week before admission, the patients had visited a friend who was also coming from India, but he was a permanent resident in Amsterdam, The Netherlands, at that time. Two days after the meeting, the index case had developed a vesicular exanthema, a typical clinical sign of varicella. However, information on the possible source of the virus (contact person) and the vesicular characteristics of the exanthema was not available.
Seven days after the contact with the index case, the Indian couple was admitted to the hospital. The man presented with diffuse exanthema consisting of vesicles with a narrow erythematous rim as well as a vesicular, erosive enanthema of the oral mucosa. As a striking finding, there were single large bullous lesions, measuring up to 8 mm in diameter. Additionally, the patient suffered from fever and adynamia. The woman showed multiple papulovesicular skin lesions. Overall, the male patient showed an initially severe course of varicella, whereas the female patient had a relatively mild course.
Routine blood testing revealed hepatopathy with elevated serum concentration of alanine aminotransferase (2.5x of reference) for the man. Testing of vesicle fluid for VZV DNA using polymerase chain reaction [
Single-nucleotide polymorphisms in VZV strains of the novel provisional clade VI detected in two Indian patients with varicella in comparison to other VZV clades. ORF: open reading frame, ND: not done.
Clades/ Reference | ORF 1 | ORF 21 | ORF 22 | ORF 50 | ORF 54 | ORF 60 | ||||||
strains | 508 | 685 | 790 | 33725 | 37902 | 38019 | 38055 | 38081 | 38177 | 87841 | 95241 | 101464 |
1/Dumas | C | G | T | T | A | G | T | A | G | C | T | C |
2/pOka | C | A | C | C | G | G | C | C | A | T | C | C |
2/vOka | C | A | C | C | G | G | C | C | A | T | C | C |
3/VZV11 | C | G | T | C | A | G | T | A | G | T | T | C |
4/VZV8 | C | A | C | C | A | G | C | C | A | T | C | C |
5/CA123 | C | G | C | C | A | G | T | C | G | T | C | A |
VII | ND | ND | ND | ND | ND | G | T | C | G | ND | C | ND |
VIII | C | A | C | C | A | G | T | C | A | T | T | C |
IX | C | G | C | C | A | G | C | A | G | T | C | C |
The patients received acyclovir intravenously at a dosage of 5 mg per kg body weight 3 times daily for 7 days. The man was treated additionally with systemic antibiotics. Zinc sulphate gel was used as topical antiseptic therapy. Gynecological examination of the woman showed a regular pregnancy. Both patients recovered without complications. Subsequently, the female patient gave mature birth to a healthy child.
Varicella is a common highly infectious disease with an average age of manifestation differing due to geographical location. In Europe and North America, varicella is seen in 90% of the cases before the age of 10 years [
Since the incubation period of varicella is up to 21 days, it is beyond doubt that the Indian couple described in this paper acquired varicella during their trip to The Netherlands. Both patients developed the disease within one week after VZV exposure to the index case. The novel provisional VZV clade VI was identified as the etiological agent of varicella. The provisional clade VI is considered to be a combination of the European clade 1 or 3 with the African/Indian clade 5 or clade 4 that has been found predominantly in countries of South and Central America [
Two years ago, we observed a varicella outbreak in Indian students in Magdeburg caused by the African/Indian VZV clade 5 [
The patients have given their informed consent for the paper published.
Malgorzata Kolesnik and Bernd Bonnekoh contributed equally to this paper.