Age: 9.0
Sex: M
Vaccine: VARCEL
Symptoms: CSF monocyte count negative, CSF neutrophil count negative, CSF protein increased, CSF test, CSF virus identified
Clinical narrative: Information has been received from a physician through a published literature article, concerning "one of the first cases of vaccine-associated aseptic meningitis after herpes zoster in a previously healthy 9 year old male who presented to the emergency department (ED) with history of a painful rash for 5 days and headache for 1 day. The child had presented 6 days earlier to an outside hospital with left arm pain. Radiograph results of the arm and shoulder done at the time were negative. During the subsequent 5 days, the child developed a painful and pruritic vesicular rash, which started on the proximal left arm and progressed down to the forearm. On the day of presentation to the ED, the child also complained of headache, increasing fatigue, and pain in the neck and the back. There was no history of fever or vomiting. There was no history of recent contact with anyone with a rash or varicella-like illness. History related to review of other systems was negative. His immunizations were up to date, including a dose of VARIVAX (Merck) at 1 year of age. He had never had a chickenpox-like illness. There was no significant personal or family history of illness. On presentation to the ED, his blood pressure was 136/194 mmHg, pulse rate 129 beats/min, respiratory rate 22 breaths/min, temperature 38.6C (101.5 F), and oxyhemoglobin saturation by pulse oximeter 100% in room air. The child was alert, responsive, and oriented to time, place, and person. He had a vesicular rash on the outer side of his left arm and forearm, with a few scattered vesicles on the palm of the hand consistent with involvement of the C5, 6 dermatome. The child had neck stiffness and a positive Brudzinski sign. There was no evidence of any neurologic deficit. Funduscopy of both eyes showed normal optic discs with sharp margins. Cardiac, pulmonary, abdominal, and musculoskeletal examination results were normal. The CBC count and basic metabolic panel results were normal. Laboratory analysis of cerebrospinal fluid revealed 30 WBCs/mm3 (79% lymphocytes, 16% monocytes, 1% segmented neutrophils, and 4% atypical lymphocytes), and 3 RBWs/mm3, protein 55 mg/dL, and glucose 54 mg/dL. The blood glucose level at the time was 117 mg/dL. The Gram stain and culture results of the cerebrospinal fluid were negative for bacteria. Scrapings from the skin vesicles tested positive for varicella-zoster virus and negative for herpes simplex virus by real-time polymerase chain reaction. Cerebrospinal fluid was also positive for varicella-zoster virus and negative for enterovirus and herpes simplex virus by real-time polymerase chain reaction. Lymphocyte subset testing done as part of an immunology evaluation was normal. The skin lesion and cerebrospinal fluid specimens were sent to the VZV Laboratory of an agency, where they were confirmed to be positive for the vaccine strain of varicella-zoster virus. The VZV Laboratory polymerase chain reaction assays target different vaccine-associated single-nucleotide markers in open reading frames 38, 54, and 62 of the varicella-zoster virus genome to confirm the presence of varicella-zoster virus DNA in a specimen and to reliably discriminate vaccine from wild-type strains. The child was treated with acyclovir in an anti-meningitic dose (1,500 mg/m2/day divided every 8 hours). His hospital stay was uneventful, and he was discharged home on day 6 of admission, with a peripherally inserted central catheter to complete a 10-day course of acyclovir for varicella zoster meningitis." The reporter felt that vaccine-associated aseptic meningitis and herpes zoster were related to therapy with VARIVAX (Merck). Follow up information has been received on 24-AUG-2012, from a literature article. The following neurological complications of varicella vaccine have been reported. Case male patient who was vaccinated with VARIVAX (dose not reported) at 1 year of age. At 9 years, the patient developed zoster lesions on his proximal left arm, which progressed to the forearm, followed by meningitis. The article does not state where the patient was vaccinated. The Centers for Disease Control (CDC) confirmed the presence of Oka Varicella-Zoster-Virus (VZV) in both zoster lesions and Cerebrospinal Fluid (CSF) from the patient. Additional information is not expected.