Age: 23.0
Sex: M
Vaccine: VARCEL
Symptoms: Diarrhoea, Dysuria, Herpes zoster, Infection transmission via personal contact, Laboratory test abnormal
Clinical narrative: Information has been received from a health professional concerning a 23 year old African American male with a developmental delay and an allergy to meperidine hydrochloride (DEMEROL), unknown underlying medical conditions, and a history of chickenpox as a child (positive titers in Sept2003). The pt is also status post a kidney transplant in 1995 via living related donor secondary to ESRD and PUV which failed secondary to noncompliance of medication. He had been on dialysis pending a second kidney transplant. On 23Sep03, the pt received his second kidney transplant from a living related donor and was placed on appropriate immunosuppression post transplantation. During July and August 2004, the pt was in the same house with a nephew who was vaccinated with a dose of varicella virus vaccine live (the date of vaccination, health history, and possible exposure to chickenpox were not known). It was noted that the nephew developed a rash in July2004. The 23 year old boy's medications at the time of exposure to his nephew included mycophenolate mofetil (Cellcept), prednisolone, nitrofurantoin (Macrodantin), tacrolimus (Prograft), potassium (unspecified), amlodipine besylate (Norvasc) and cytomegalovirus immune globulin (cytogam). The pt then developed a rash. Possible secondary transmission was noted. The timing of the exposure and the details of the rash were not known. The reporter indicated that the pt had been hospitalized. The reporter plans on submitting a VZV ID and VZV cell culture specimen (lesion). Follow up information received from a nurse practitioner and medical record indicated that on 05Aug04, the 23 year old pt presented to our office for a health check and his father reported that a bumpy rash had started on 30Jul04/31Jul04. When seen in the office, the pt was diagnosed with chickenpox, which were in general distribution. No other symptoms were noted. The pt was treated with acyclovir. A specimen from his chickenpox rash was taken and found to be DFA+. This specimen was later found to be VZV + and identified with the WTV via PCR analysis. On 07Aug04/08Aug04, the pt's father called the office to say that the pt was having difficulty urinating. They were instructed to go to the ER if this continued to be a problem. On 09Aug04, the pt's creatinine was 14, up from 2.0. He was admitted to the hospital with increased creatinine, severe diarrhea thought to be secondary to the acyclovir, neurogenic bladder secondary to varicella virus, and weight loss. Admission diagnosis included anuria, azotemia, varicella, s/p renal status, and history of MRSA. During the hospital course, the pt also had anemia, neutropenia, and a left buttock wound. The pt was admitted with an active varicella infection with super infected lesions on his face. The pt was placed on droplet and contact precautions. The pt was started on vancomycin for the lesions azotemia and diarrhea. The lesions continued to improve and the 10 day vancomycin course was completed. On 11Aug04, the pt developed anemia with a hemoglobin of 6.2. Two units of blood were transfused, and his hemoglobin was stabilized at 7.3 at discharge. On 13Aug04, the pt was noted to be neutropenic with a WBC count of 0.4. The pt was placed on filgrastim (Neupogen) times 4 days. The WBC count increased to a high of 62.8 and at discharge the pt's CBC showed a WBC count of 49.7, hemoglobin 7.3, hematocrit 21.5, ad platelets of 445. The pt was noted to have a skin breakdown of the left buttock secondary to diarrhea. The pt was started on barrier cream at each diaper change. Wound cultures showed staphylococcus areus candida and Enterococcus faecalis. The pt was discharged to home with home health for wound care. The pt was recovering from the chickenpox, increased creatinine, weight loss, and neurogenic bladder with some residual facial scarring from the chickenpox when he developed left arm shingles on 19Aug04. A lesion from the rash was DFA+, and was not sent on to the VZV ID program. Cultures remained negative for both herpes and varicella. The pt was discharged from the hospital on 25Aug04 in stable condition. Recovered except for facial and left arm scarring (at discharge there were no active vesicles). On 08Sep2004, the pt's VZV antibody test was reported as VZV AB IGG 4.46 He had not had any blood products at the time of the antibody testing. The reporter reconfirmed that this was WTV and not secondary to the vaccine. Additional information has been requested. Follow up 03/03/05: Patient has not recovered from the adverse event(s).