Age: 1.0
Sex: F
Vaccine: MMR, PNC, VARCEL, MMR, PNC, VARCEL
Symptoms: Erythema multiforme, Haemoglobinaemia, Meningitis, Pyrexia, Red blood cell sedimentation rate increased
Clinical narrative: Information has been received from a physician concerning a 12 month old female who was vaccinated with MMRII and varicella virus vaccine live. Ten days later, the pt developed a fever and rash. The physician noted that under the microscope he can not determine what caused the rash. Follow-up from the physician indicated that he was the pathologist who had received the skin biopsy specimen of the rash from the pt's dermatologist. He received the specimen, 3 days prior to the pt's death. Additional information from the pt's pediatrician, indicated that the child received MMRII, varicella and Prevnar on 4/13/01 and on 4/25/01, the pt was brought into the office with a fever of 101F  associated vomiting, lethargy, dehydration and a generalized rash that looked like erythema multiforme. Another physician was working with the physician that day and they both agreed that it looked like erythema multiforme. The parents were told to bring the pt back on 4/26/01 for a follow-up visit. On 4/26/01, the rash still appeared as erythema multiforme, however, it was not as generalized and was more discrete. The parents reported that the child was also on a Chinese herbal medicine and the baby sitter reported that the child had eaten a new kind of fish that night. The pediatrician referred the pt to a dermatologist and when he saw the pt, he reported that he had never seen anything like the rash that the pt presented with and he did a skin biopsy. The next day, the pediatrician called the pt's home to check her condition. The child's baby sitter reported that the child was doing fine, eating, drinking and the rash was getting better. On 4/27/01, the pediatrician called the pt's home again and wanted the child to come in to be seen, however, the family was reluctant because they reported the child was doing fine, the rash had faded and the child's fever was gone. On the night of 4/28/01, the family took the child to the ER. The ER physician called the pt's pediatrician and told her that the pt presented to the ER with fever, crying with no tears and dehydration and vomiting. The ER physicians were unable to get an IV line into the child, the child went into shock and arrested, with failure to revive. The family refused to autopsy. The cause of death on the death certificate was meningococcal meningitis. The pediatrician reported that the cause of death could not possibly be meningococcal meningitis because the blood cultures that she had done on the pt at the height of the rash on 4/25/01 were negative and the fever and rash had gone away without any prophylaxis treatment. The pt's father could not tell the pediatrician the name of the Chinese medication, only that it was herbal Chinese medication. The pediatrician reported that a piece of the skin biopsy was sent for PCR analysis and the pediatrician was unsure if this would be conclusive or not. The pediatrician also reported that there was no blood obtained for IgG or IgM titers. The pediatrician noted that she did not know the cause of death. The child's body was being taken to another country to be buried. Follow-up from another physician indicated that the pt had negative blood cultures taken in the PCP's office and he was not sure where the dx of meningococcal meningitis came from without further lab support. He was questioned as to whether the community where the child lived may need prophylaxis and from the description of the child's symptoms, he did not feel the symptoms were consistent with a meningococcal bacteria. The physician noted that the child looked septic on admission to the hospital and he wondered if the child was actually dehydrated. The physician was unsure if the child 1st respiratory or cardiac arrested, however, he did feel that it would be unusual for a child this age to 1st cardiac arrest. The physician confirmed that the child did eat a different type of fish and wondered if the child may have contracted a Vibrio infection from ingesting infected raw fish. Conflicting information from this physician indicated that the child was seen on 4/22/01 by the PCP and a maculopapular rash was dx'd as an atypical measles type rash. The child's rash then reportedly improved however on admission to the ER, the child reportedly had a florrid, "violatious" rash. The physician wondered about the child's immune status, since the child lived on a commune where group marriages occurred. The commune consisted of approx. 300-400 people. The physician noted that this was all just philosophical discussion since an autopsy was not performed and the cause of death will probably not be known. No further details were provided. Additional information received on 05/23/2001 indicated that PCR results from the parafin block extraction were negative for V2V. Additionally the specimen was concentrated down, in hopes of going further and making it more sensitive; however, it was still negative for V2V. The patient's physician was planning to have a PCR done for measles, as "atypical measles" was one of the clinical diagnoses for the pt. The physician reaffirmed that she did not believe the child's rash was varicella. The physician plans to have additional specimens sent for measles PCR. Additional info has been requested. Follow-up info has been received from a physician who stated that, according to the CDC, the skin tissue tested neg. for MMR. He also reported that the VZV was neg. Additional information has been requested.This is an amended report. The pt's age was changed from 12 months to 13 months. This is a corrected report as amended.