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Further replication occurs in the viscera, followed by a secondary viremia, with viral infection of the skin.Virus can be cultured from mononuclear cells of an infected person from 5 days before to 1 or 2 days after the appearance of the rash.Adults may have more severe disease and have a higher incidence of complications.Respiratory and gastrointestinal symptoms are absent. Children with lymphoma and leukemia may develop a severe progressive form of varicella characterized by high fever, extensive vesicular eruption, and high complication rates.Primary varicella infection (chickenpox) was not reliably distinguished from smallpox until the end of the 19th century.

In individuals who have not been vaccinated with varicella vaccine, the rash is generalized and pruritic and progresses rapidly from macules to papules to vesicular lesions before crusting.The virus is believed to replicate at the site of entry in the nasopharynx and in regional lymph nodes.A primary viremia occurs 4 to 6 days after infection and disseminates the virus to other organs, such as the liver, spleen, and sensory ganglia.Herpes zoster, or shingles, occurs when latent VZV reactivates and causes recurrent disease.The immunologic mechanism that controls latency of VZV is not well understood.

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