Age: 2.5
Sex: F
Vaccine: HEP, VARCEL
Symptoms: Impetigo, Pain, Pruritus, Rash vesicular
Clinical narrative: Informational has been received from a registered nurse concerning a30 month old Hispanic healthy female with a past medical history of skin sensitivity and eczema, and allergy to augmentin, and significant family history of Hashimoto's Thyroiditis (maternal gradmother) who on 19JUN2002 was vaccinated in the left outer upper thigh with a first dose of 0.5ml dose of varicella virus vaccine live. Concomitant therapy that day included a second dose of hepatitis b vaccine and a first dose of PPD. On 19SEP2003 the pt developed a rash that had not been seen by the physician. The child's mother describes this as a varicella type rash. The child developed 10 generalized vesicular lesions on her face, trunk and legs. These lesions resolved within 3 days. On approximately 23SEP2003, one day after resolution of the initial lesions, a shigles rash developed on the child's upper leg. At the time of the report, the rash on the upper leg still remained. The rash was treated with oral acyclovir and diphenhydramine hydrochlorine, benadryl. On 10OCT2003, the rash still persisted and was reported as being painful and itchy. However, at this point the child was noted to have an "impetigo" type rash near the herpes zoster type rash. The child was prescribed antibiotics. Lesions of the herpes zoster rash were  unroofed and a vesicular swab specimen was submitted for culture. The reporter stated that the child had no evidence of immunodeficiency and that although it may have been a case of breakthrough rash that the child developed on 19SEP2003, "it seems too soon to have an occurence of herpes zoster development on 23SEP2003". The reporter indicated that she plans to check with the lab and obtain the swab specimen for PCR analysis. She is also checking with the mother to possibly send additional specimens. No other symptoms were reported. Unspecified medical attention was sought. There was no product quality complaint. Follow up information received on 14OCT2003 from a registered nurse indicated that the original specimen for the VZV ID program that was sent to the  hospital lab was not from the herpes zoster site and did not grow VZV. This speciment had been taken from an impetigo area. The reporter indicated that the new specimens were obtained from the herpes zoster site (a scab and a swab of lesion under the scab was obtained) and will be sent on 15OCT2003. The reporter indicated that the child is improving. Additional follow up information indicated that the shingles rash developed at the site of injection approximately 460 days post vaccination. On 24SEP2003 the child developed itching and pain at the injection site. Shingles and impetigo  were noted, with greater than 30 lesions. A large cluster of the lesions were on the left upper thigh scattered from the vulva to the upper buttocks. The herpes zoster was described as a large vesicular patch on the left upper thigh that was painful and itchy. The pt was treated for shingles and impetigo with asyclovir, atarax and cephalexin. On 12OCT2003 a specimen was obtained, and on 14OCT2003 the specimen was sent to the laboratory. The source of the specimen was a vesicle and a scab. It was noted that the pt had questionable varicella lesions on her face, trunk, and arms from 19JUL2003 to 23SEP2003. The child had no recent exposure to chickenpox or shingles. The outcome was reported as recovering. Follow up information indicated that the specimen was received. Additional follow up information received from a registered nurse indicated that on 24SEP2003 the pt had a severe outbreak of shingles on her left upper thigh. This progressed into impetigo. The rash did not occur at the site of injection or elsewhere within 42 days of the vaccination. The herpes zoster was described as >20 red papules with blisters from her midline vulve to her upper buttocks, concentrating in the left upper thigh area for 2 to 3 weeks. The pain was identified as a 6 (with 0 being the least 10 being the most). There was no history of chickenpox, no recent exposure to chickenpox or herpes zoster, no direct fluorescent antibody done and no photo taken. The culture was treated with acycloclovir. The impetigo was treated with cephalexin. The outcome was reported as recovered approximately 15OCT2003. Additional follow up information received on 30OCT2003 indicated that the PCR results were not yet received. Additional follow up information received on 07NOV2003 indicated that the PCR result were negative. The specimen was obtained on 12OCT2003 and sent to the laboratory on 14OCT2003. The source of the specimen was a lesion, described as a vesicle and a scab. The specimen arrived in the laboratory on 15OCT2003. The VZV DNA was not amplified. The B-globin DNA was amplified. The interpretation was adequate specimen with no VZV identified: negative. Additional follow information received on 13NOV2003 noted that the pt had recovered, but according to the mother there may be some scarrring. The pt had not been assessed by the HCP. Additional information is not expected.