Age: 29.0
Sex: F
Vaccine: VARCEL, VARCEL
Symptoms: Rash, Secondary transmission, Varicella
Clinical narrative: Information has been received from a physician concerning a 29-year-old female (previously reported as 14-year-old) with penicillin allergy (causes swelling), allergy to risperidone, cyclosporin A (causes respiratory distress) and methylphenidate as well as a history of bone marrow transplant (APR-2003 also reported as 2004), acute lymphocytic leukaemia (ALL) and acute myelocytic leukaemia (AML) who on an unknown date was vaccinated with a third dose of VARIVAX (Oka/Merck).  Concomitant therapy included valacyclovir HC1 (VALTREX), aspirin and fluoxetine HC1 (PROZAC).  On an unspecified date it was reported the patient had "transmission from VARIVAX (Oka/Merck)".  It was noted the patient was sitting next to a child with a rash.  The patient is now hospitalized with a varicella rash.  The physician also reports that he does not know if there was an adverse experience, he wants to "know if it is vaccine strain or infection".  A product quality complaint was not involved.  The patient was vaccinated with all 3 doses of VARIVAX (Oka/Merck) prior to bone marrow transplant (BMT).  It was also noted "child had confirmed varicella rash 1 week prior to the patient's rash".  Following exposure the patient developed a generalized rash.  The rash was biopsied which "grew out varicella".  No other complications were reported.  The patient improved and was discharged home about 2 weeks ago.  On an unspecified date the patient recovered.  Follow-up information noted a 29-year-old white female with an allergy to penicillin (swelling and rash), cyclosporin (anaphylaxis) and asparaginase (shortness of breath), as well as a history of ALL, biphenotypic leukemia status post allogeneic bone marrow transplant in 2003 presented with symptoms of acute varicella zoster virus infection.  Five days prior to admission, the patient came into contact with a child suspected of having varicella.  Four days prior to admission, the patient began felling flu-like with myalgias, sore throat and some stomach pain.  Two days prior to admission, the patient had a fever up to 105 degrees Fahrenheit with a rash, which was red and itchy and has blisters on her chest.  One day prior to admission, the patient went to the emergency room and was given acyclovir orally and told to follow-up in the clinic.  On the day of admission, the patient noticed a worsening of the rash, which spread to the face, arms, abdomen and back.  The rash was extremely itchy.  She had a fever on the day of admission up to 101.5 degrees Fahrenheit.  The patient denied any cough or abdominal pain.  In the emergency room she was started on maintenance fluids and intravenous acyclovir 500 mg every 8 hours.  She was then transferred to the hospital and admitted.  It was also noted the patient had diffuse vesicular lesions on her face, trunk, back and arms.  The lesions were mostly concentrated on her upper back and face.  The lesions were vesicular on an erythematous base.  None of the lesions were open, weeping or crusted over.  The patient exhibited mild pharyngeal erythema, but no exudate.  The patient had prominent anterior cervical nodes.  The abdomen had mild tenderness to deep palpation in the epigastric region.  Treatment Plan: the patient was continued on acyclovir intravenous 500 mg every 8 hours on the night of admission.  She was placed on maintenance fluids at 0.9 normal saline at 125 mL/hr.  She was given calamine lotion as needed as well as acetaminophen TYLENOL 325 mg orally every 6 hours as needed for fever.  The patient was placed in airbourne precautions.  She was given diphenhydramine 50 mg orally every 6 hours as needed for pruritis.  IgG, IgA and IgM levels were drawn per the request of the pediatric hematologist and oncologist.  These levels all can back as normal.  The following day, the infectious disease consult team examined the patient and increased her dose of acyclovir to 700 mg IV every 8 hours.  They also swabbed a few of her vesicular lesions for varicella zoster and herpes simplex nucleic acid amplification test.  The varicella zoster amplification test came back positive, while the herpes simplex test was negative.  A chest x-ray showed no acute cardiopulmonary disease.  The patient's CBC and LFTs were checked daily throughout the course of admission.  Her liver enzymes remained at baseline with no elevation of AST or ALT.  The patient remained on the recommended dose of intravenous acyclovir for 4 days until all of her lesions had crusted over.  On discharge (12-MAR-2008), the patient will go home with valacyclovir (VALTREX) 1 g orally 3 times a day for 10 days per the infectious disease recommendation.  She will also follow-up with a CBC and liver enzymes 1 week from today.  The patient has a history of right-sided internal carotid artery occlusion from 3 years ago.  This worked up by the vascular surgery team.  The occlusion was found to be complete and therefore, no action was taken.  The patient has remained asymptomatic over the past 3 years.  During this admission, a repeat bilateral carotid doppler was obtained, which indeed showed a chronic right-sided internal carotid artery occlusion.  Vascular surgery was consulted and they recommended no further interventions.  Follow-up instructions: the patient is to follow-up with her primary medical doctor and have CBC and LFTs drawn 1 week after discharge.  Continuing medications included aspirin 81 mg PO daily and fluoxetine 20 mg PO daily in the morning.  Date of admission 07-MAR-2008.  Date of discharge 12-MAR-2008.  The physician reported that he did not have any information of the patient's vaccination dates.  The physician indicated that he received the VZVIP questionnaires and he would be sending in a sample collected from a scraping of a "varicella rash".  The patient was enrolled in the varicella zoster virus identification program to identify if VZV is present and if it is present to identify if it is associated with the wild-type (WT) VZV strain or with the OKA/Merck VZV strain.  The sample of the lesion was collected on 09-MAR-2008.  The sample was taken from a papule/lesion from the breast.  It was reported the patient had papules vesicles with numerous lesions distributed on the face, trunk, arms and legs.  The PCR results for the specimen retrieved from the breast identified the presence of VZV WILD TYPE STRAIN.  This is one of several reports received from the same source.  Additional information is not expected.  All medical records will be provided upon request.