Age: 36.0
Sex: F
Vaccine: TDAP, VARCEL
Symptoms: Hepatic failure, Herpes zoster disseminated, Immunoglobulin therapy, Intensive care, International normalised ratio increased
Clinical narrative: On 4/10/2016, began to experience lower back pain, chest pain, and dyspnea. Admitted to an outside hospital on 4/14/2016. There, she underwent workup for acute coronary syndrome which was negative overall. She began to develop lower quadrant abdominal pain and therefore a CT was obtained which revealed an ovarian cyst but was otherwise unremarkable. Her pain was thought to be due to constipation, and therefore she underwent an aggressive bowel regimen and subsequently developed diarrhea. Her diarrhea was then tested for clostridium difficile which was positive (however she had been tested positive 2 months prior) and treatment was initiated with oral vancomycin. She also began to develop ecchymoses, a rash across her face and reported petechiae. Her LFTs progressively increased, she developed progressive thrombocytopenia and elevated LDH. Her renal function continued to worsen through her stay, climbing from ~3 to >4.5 prior to transfer. She developed an increasingly severe leukocytosis. It was felt her rash was most likely petechiae/purpura and, given her laboratory findings, there was concern for TTP. Given the inability to perform exchange transfusions at the hospital, she was given FFP and transferred to another hospital for further management. Upon admission on 4/18/2016, she stated she continued to have significant lower quadrant abdominal pain and reported itching and increasing pain associated with her rash. She denied changes in vision, but has noted increased eyelid swelling. She noted her pain is constant in nature, located predominantly in her lower abdomen. She had been unable to tolerate a diet, vomiting everything she tried to consume. She had not noted pain in her mouth. She reported a mild headache and some mild neck stiffness that she attributed to lying on the hospital bed. She had not been confused. She continued to have back pain located in her low back, approximately midline that worsens with movement. Her examination is most consistent with a diffuse, vesicular rash that was most concerning for disseminated herpes zoster, especially given her recent administration of the VZV vaccine in her immunocompromised state. Her progressive thrombocytopenia, along with a decreased haptoglobin, mildly elevated INR and low fibrinogen are concerning for possible DIC secondary to this disseminated infection. Alternatively, her symptoms could represent a diffuse palpable purpura with progressive thrombocytopenia secondary to TTP, as supported by her anemia, increasing creatinine, and severe LDH elevation. Her smear showed <1 schistocyte per hpf. Her rash is less consistent with purpura. Since the patients admission on 4/18, she reported increased work of breathing with SOB and central chest pain. She was placed on NIPPV, but was unable to tolerate this for very long. She was placed on 4L NC with an appropriate Sa02 >92%. Additionally, she developed tachycardia and became febrile concerning for sepsis, therefore she was stated on empiric therapy for HCAP. In the setting of worsening AKI on CKD, the critical care team was consulted for initiation of CVVH. Prior to the patient's physical transfer to the ICU, she became acutely agitated and confused, insisting that the staff was attempting to kill her. She was given 5 mg haloperidol and restrained after she attacked the nursing staff. During this process, she removed all but one of her peripheral IVs and the decision was made to gain central venous access prior to transfer. A right IJ trialysis catheter was placed and, while attempting to place a left IJ triple lumen, the patient desaturated and required intubation. As of the time of this VAERS event report, the patient remains intubated and is receiving CVVH as well as plasmapheresis. Other treatments include high-dose acyclovir, daily IVIG, and a one time IM dose of 625 units varicella zoster immune globulin on 4/21/2016. She is also requiring norepinephrine infusion, stress dose hydrocortisone, n-acetylcysteine (for liver failure), and cefepime, metronidazole, and vancomycin (oral for c diff and IV for possible systemic infection). Patient is currently still admitted to the ICU.