Sex: F
Vaccine: VARCEL
Symptoms: Blister, Rash vesicular, Scar, Secondary transmission, Skin lesion
Clinical narrative: Information has been received from a pediatrician concerning a 27 (also reported as 23-26) days old female patient whose VZV serology negative during pregnancy mother was vaccinated SQ on with a 0.65 ml dose of VARIVAX (Merck) as part of a routine vaccination post partum on 25-JAN-2010, 3 days after she gave birth via C-section the female patient. On 18-February-2010 the patient was diagnosed with chickenpox, she had approximately 60 lesions total on the face and body, with distribution as follows: approximately 15 lesions on the face; 5 to 10 on each extremity; and 20 on the trunk. It was reported that when the infant presented to the office, one of the pediatrician's colleagues initially saw her and was quite alarmed/concerned about the infant possibly having wild-type chickenpox; an infectious disease specialist was consulted. The following day, the pediatrician saw the infant for the first time and noted that she had more lesions/vesicles, the pediatrician asked the mother whether she had been vaccinated, and the mom confirmed that she had been vaccinated with VARIVAX (Merck) post-partum, prior to the consult with the specialist. The mother was questioned "up and down" if she had any post vaccination rash, and the mother said she did not. She was also asked about any injection site rash or blister(s), as well as any itching, redness or irritation at the injection site or elsewhere however, the mother denied having any such signs/symptoms post vaccination. The pediatrician reported that the mother was primarily bottle-feeding the patient, but was partially breast feeding her as well. The reporting pediatrician chose to start the infant on oral acyclovir, initially at 20 mg/kg and then subsequently reduced to 15 mg/kg four times daily. She reported the acyclovir was "highly effective" and within 48 hours, 95% of the lesions had scabbed over and the infant was developing very few new lesions, the infant did not have any fever or other systemic signs/symptoms. The pediatrician sent a swab sample(s) from the infant's lesion(s) to the CDC for PCR analysis; she confirmed that the CDC identified the presence of vaccine strain VZV in the infant's lesion sample. The pediatrician felt that respiratory or other skin transmission were more likely modes of transmission than breastfeeding. She noted that the mother could have had just 1 lesion and/or scratched open her skin without even knowing it. In this case, the infant developed chickenpox 25 days after the mother was vaccinated, so it was possible that the mother did not recall a slight reaction post vaccination. According to the pediatrician, in this particular case, the infant did not meet the criteria for hospitalization for IV acyclovir, but did very well with the oral dose and had rapid improvement of her signs/symptoms. At the time of the report the patient had recovered with 2 scars on the forehead. The presence of vaccine strain VZV was reportedly identified in the infant's lesions; Centers for Disease Control and Prevention (CDC). It was also reported that varicella IgM was positive for the mother. Follow up information has been received from the physician who stated that she counted 50-60 vesicular lesions on the second day of the illness. It was reported that the patient was never febrile therefore, never met criteria for hospitalization and IV acyclovir. Results from the CDC were provided which showed adequate specimen collection from 2 swabs and media submitted for analysis and positive results for VZV DNA detection. Follow up information was received and indicated that the patient's mother was vaccinated on 25-JAN-2010 with a dose of VARIVAX (Merck) (Lot # 665421/1163Y) into her left arm. On 17-FEB-2010 at 09:00, twenty days after maternal vaccination, the patient developed a vesicular rash. PCR was positive for varicella. PCR genotyping was positive vaccine VZV genotype. The patient was afebrile. On day #2, she had a classic varicella rash with about 60 vesicles. She was started on acyclovir orally. It was reported that the patient had not developed new vesicles and that the vesicles were scabbed in 24-48 hours. The patient recovered on 25-FEB-2010. The patient was not hospitalized. It was confirmed that the patient's mother was healthy and had no medical history conditions. No illnesses at the time of vaccination were reported either for the patient of her mother. According to the physician, the patient did not have other problems or other infections since her chickenpox. The patient was exclusively bottle fed for the first three days, when the physician saw the patient in the hospital; the mother was encouraged to attempt breastfeeding. On the date of vaccination, the mom started breast feeding the patient, the physician estimated this to be 25% of the time. The physician felt that the mom may have missed giving the infant protective antibodies by not breastfeeding at birth. Even though the mother had negative varicella antibodies the physician felt that the patient may have still received added protection from the other proteins in the colostrum. The patient's mother increased the amount of breastfeeding, however still continued to primarily bottle feed the infant. Finally, the physician mentioned that she felt strongly that women with negative serology should be vaccinated post partum vs. during pregnancy. She was hoping that this case would support the use of oral acyclovir as a treatment for infants like the patient who did not meet criteria for hospitalization for IV acyclovir. Follow up information has been received from the physician who indicated that the vaccine site was covered with band aid for one day. The mother began breast feeding pumped breast milk the third day of life, about BID, for 4 weeks (pumped milk). She held the baby in her left arm when feeding her. The patient's mother was vaccinated with VARIVAX (Merck) in the left arm and the mother had no injection site pain or itching. Given that the patient developed a rash about 3 weeks after the vaccination; this timed suggested infection at the time of mother's vaccination. Additional information is not expected.