Sex: M
Vaccine: VARCEL
Symptoms: Lymphocyte percentage, Neutrophil percentage decreased, Pain, Pain in extremity, Platelet count normal
Clinical narrative: missed his second dose of the varicella-zoster vaccination as a younger child; Literature Report.  This literature marketed report has been received from the authors of a published literature article, titled as stated above and refers to a 12-year-old male patient.  The patient's medical history was notable for frequent streptococcal pharyngitis infections, resulting ultimately in a tonsillectomy. His concurrent conditions and concomitant medications were not reported. The patient had no history of chickenpox.  On an unknown date, he was vaccinated with the first dose of varicella-zoster vaccine (manufacturer unknown) (strength, dose, route of administration, vaccination site, lot number and expiration date were not reported) for prophylaxis. On an unknown date (as a younger child), the patient missed the second dose of varicella-zoster vaccine (manufacturer unknown) (product dose omission issue). The patient was up to date on all his other childhood immunizations.  The patient was tested positive (hospital-based, rapid molecular testing) for severe acute respiratory syndrome Coronavirus 2 (SARS CoV-2). His course of Coronavirus disease (COVID) was brief and unremarkable. 6 weeks later, he played soccer game (he was right hand dominant soccer player) and he had no current symptoms referrable to this infection at the time of this soccer game. He began the game in his usual state of good health, and he had been "stepped on" during the game. On an unknown date, two days after a tournament game the patient presented to sports medicine for a complaint of acute onset right arm pain. While playing the game he was pain-free. He woke up the following day with his right arm hurting. Plain films of the right humerus were negative, and he was diagnosed with a contusion and discharged home with recommendations to rest, ice, and take over-the-counter (OTC) analgesics. The family was told to follow-up with their pediatrician in 3 to 5 days if no improvement. Three days after that initial visit to the same ED, he represented with pain which was now preventing him from going to school as well as participating in sport. His pain was worsening and now keeping him up at night, and it was not responsive to acetaminophen. His pain was in the axilla radiating to his hand. He had incurred no additional trauma since his first ED visit. He was afebrile and the documented examination consisted of a statement of "no swelling, edema, or deformity" of the extremity. A shoulder sling was dispensed, and he was referred to sports medicine. On initial evaluation in sports medicine, 7 days after the sentinel soccer game, his mother reported that pain control, with OTC analgesics including ibuprofen and the dispensed sling, had been inadequate to this point. The patient was found to be guarding his right arm with pain limited active range of motion. He looked uncomfortable but was nontoxic and afebrile (temperature: 98.6 [unit not reported]). Inspection of his right arm revealed a vesciulopapular rash in a C6/7/8 dermatomal distribution. This rash was reported to be painful and nonpruritic. Some of the vesicles were crusted over and none were actively draining. There was no associated erythema or signs of cellulitis. He underwent the following laboratory tests: white blood cells (WBC) count: 3.5 (units not reported), hemoglobin (Hgb): 14 (unit not reported), platelets: 212 (units not reported), lymphocytes: 34 (units not reported), neutrophils: 48 (unit not reported), bands: 3 (unit not reported), erythrocyte sedimentation rate (ECR): 2 (unit not reported), C- reactive protein (CRP): 0.5 (unit not reported). All test results were within normal limits with the exception of a mildly low WBC count and bands. Also varicella zoster virus (VZV) polymerase chain reaction (PCR) test was obtained by skin scrapings of active vesicular lesions, and the result was positive. The patient was treated empirically for herpes zoster (HZ) with valacyclovir 1000 milligram (mg) three times a day for a 7-days course. Weight-based dosing of naproxen 375 mg, twice a day (bid) was prescribed for pain control, and the sling also was endorsed for use in pain control. The patient was asked to refrain from sports and school. The patient was instructed to cover his lesions with a long-sleeved shirt and gloves, and avoid any very young (nonvaccinated), elderly, or immunocompromised relatives. The patient was seen for a regularly scheduled follow-up 14 days after the putative injury. He was much improved with full strength and pain-free range of motion, and he had discontinued his sling. He was asked to follow-up with his primary care provider to receive his second varicella vaccine and return to school and play instructions were given. These included completing his course of valacyclovir and waiting a week to return to sport and school.  A copy of the published article is attached as further documentation of the patient's experience.