Age: 1.0
Sex: M
Vaccine: VARCEL
Symptoms: Rash papular, Rash vesicular, Red blood cell count increased, Scab, Skin lesion
Clinical narrative: Initial information was received from a physician and additional information was received from a nurse practitioner. The physician reported that on an unspecified dates the 9 year old (also reported as 5 year old by the N.P.) male patient received 2 doses of VARIVAX at the appropriate ages. The patient never had a documented case of chickenpox after VARIVAX. On 09-JUN-2010 the patient had a severe case of herpes zoster. A phone call was placed to the physician's office and the N.P. answered the call. The N.P. reported that the patient's shingles lesions were on his face and scalp and he had mostly scabs remaining. She thought they would have the patient came in on 18-JUN-2010 to obtain a sample of the lesions. The N.P. reported that the treatment included acyclovir both IV and orally and confirmed that the patient was hospitalized for 24 hours. The patient's outcome was not provided. Medical records and phone call were received from a registered nurse regarding the 9 year old male patient. The patient's past medical history included eczema, mild asthma, hemoglobin C trait, innocent cardiac murmur, allergies to peanuts, tree nuts and eggs and a history of pneumonia (18-DEC-2001), URI and bronchitis. The patient had no known drug allergy or known history of chickenpox per patient's mother. On 01-MAY-2002 the patient was vaccinated with the first 0.5 ml dose of VARIVAX (vaccination site unknown). On 14-JUN-2008 the patient was vaccinated with the second 0.5 ml dose of VARIVAX (lot # 660217/0167X, vaccination site unknown). Concomitant therapy included ZYRTEC. There was no rash occur at the site of injection of elsewhere within 42 days of the vaccination. The patient had no recent exposure to chickenpox or herpes zoster. On 10-JUN-2010 (previously reported as 09-JUN-2010), the patient developed herpes zoster. The body temperature taken in office as 99.2 F. The patient experienced pain (quantified as 10 (most)). The patient had multiple lesions with distribution of lesions which stopped midline of forehead, he had some large lesions on his left upper eyelid, left temple and on his scalp. A direct fluorescent antibody test was not done. On 11-JUN-2010 the patient had an emergency visit in the office with complaint of possible shingles. The patient's mother stated that the patient was seen at primary care physician due to they thought the patient had poison ivy. Mom stated PCP believed the patient had shingle and noted the patient was vomiting for 1 day. Mom stated the patient not holding down anything and the patient had lost 3 pounds per PCP scale. Mom stated the patient was also seen at ophthalmology today due to the "shingle being around the patient's left eye". Upon assessment, the patient with crusty red rash on left side of head and forehead surrounding left eye. The patient with tachy nm. respiration easy. The note for the emergency department on 11-JUN-2010 stated that the patient was initially seen by the PCP who diagnosed him with contact dermatitis and started MEDROL. Rash was worse and he was diagnosed with herpes zoster on second exam. The patient was seen in the ED due to vomiting. The patient had seen ophthalmology prior to ED visit and told no eye involvement. The physical exam revealed uncomfortable appearing; lungs, heart and abdomen were normal; vesicular rash was in Cranial nerve VI distribution and did not cross midline. The patient initially felt better after ZOFRAN, pain control and po fluids. He vomited and then felt worse again. Due to concern for dehydration if he did not take fluids, he would be admitted for intravenous fluid. Time course for benefit of acyclovir was questionable. Inpatient team would decide if the medication should be continued. HPI comments indicated the 9 year old male presenting with shingles, pain, vomiting and dehydration. He first developed red, raised lesions over his left scalp three days ago, went to see his private medical doctor, and was diagnosed with poison ivy, and started on oral steroids (note: the patient had had poison ivy on the right side of his face just last week (approximately 01-JUN-2010), thus it was quickly presumed this was a similar dermatitis). However, the lesions spread the next day to involve more of the left side of his scalp, and also his face (forehead, eyelid), and lesions were painful. Thus he returned to his PMD's office yesterday (10-JUN-2010), where he was diagnosed with shingles and stared on acyclovir. (Note: the patient had no known history of chickenpox, and did receive both immunizations as a child, but it was possible he could have had a very mild case of varicella as a child that was missed.) He was also urgently referred to ophthalmology, and saw them this morning (11-JUN-2010), and was prescribed tobramycin ophthalmic ointment as he was felt to have inflammation in his eye but not shingles involvement (per Mom). Last night, however, he started vomiting, and had kept down practically nothing since, including his medications. Emesis had been NB/NB, mostly of fluids he attempted to drink and gastric juices. No abdominal pain, no diarrhea. PMD was concerned for significant dehydration, as the patient had lost 3 pounds since his visit 3 days prior. Fevers started today, as high as 101. He had no other signs of infections - ie. no cough, congestion, sore throat. He did endorse mild photophobia, and rated the pain of the shingles lesion 6-7/10. The family was not aware of any contacts with shingles. The patient was positive for fatigue, fever, eye discharge (left eye watering), rash, nausea and vomiting. The patient was negative for congestion, ear pain, sore throat, trouble swallowing, cough, abdominal pain and diarrhea. The patient experienced poor sleep while ill. Physical exam showed fatigued; left eye mildly swollen, with mild conjunctival injection, with clear watery drainage; left side of face and scalp with erythematous, papulo-vesicular eruption in the VI distribution of the trigeminal nerve, lesions extended along the scalp to the posterior aspect of the partial area, and did not involve any areas not within the V1 nerve distribution (ie. did not involve the ear, did not involve the lower check, extended only to the tip of the nose but did not involve the nares), no evidence of bacterial superinfection, no crusting, the patient also with several ecchymoses and superficial abrasions over lower extremities, from playing outside per Mom. Other exams were normal. The ED plan indicated that the patient was on oral acyclovir since yesterday (10-JUN-2010) for shingles, with ophthalmology eval earlier today (11-JUN-2010) showing inflammation in the eye but no viral lesions, and the patient started on tobramycin ophthalmic ointment. No evidence of bacterial superinfection at this time. The patient was given oxycodone 2 mg PO x1 for pain control which showed good benefit. The patient said pain resolved. The patient could continue oxycodone and ibuprofen, as well as TYLENOL if needed, for pain. The patient was given ZOFRAN ODT 4 mg x1, then trialed PO for vomiting and dehydration. The patient took one popsicle and one box of juice and felt better, and then urinated; however, while finishing his second juice box, had a large emesis. It was noted that the patient had no tachycardic, had normal blood pressure, actually urinated three times while in the ED. The patient was given 20 ml/kg sodium chloride bolus with plan to reassess ability to tolerate PO and keep it down afterwards. The patient was admitted on 11-JUN-2010. The blood tests revealed segmented neutrophil 67, lymphocyte 16, monocyte 17, lymphocyte absolute 1.31, monocyte absolute 1.42, red blood cell 5.75, hemoglobin 15.9 and MCV level 76.9. On 13-JUN-2010 the patient was discharged home with stable condition. The patient's activity was normal and diet was regular. The medications being taken home included ZOVIRAX, TOBREX, MOTRIN, ROXICODONE and ZOFRAN. On 17-JUN-2010 the patient was seen, he was still tired and uncomfortable from his shingles. 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 VZV strain or with the OKA/Merck vaccine strain. A lesion sample was collected on 17-JUN-2010. The sample was taken from a lesion of scab. The R.N. explained that she sent a few scabs and was able to swab one of the lesions that appeared to have some fluid. On 19-JUN-2010 the patient was seen in the office again and was almost "back to normal". The patient still had some scabs from his lesions but was recovering. The patient showed a big improvement. Additional information has been requested. All available medical records will be provided upon request.