Age: 6.0
Sex: F
Vaccine: VARCEL
Symptoms: Keratitis, Ophthalmic herpes zoster, Ophthalmological examination normal, Rash, Rash vesicular
Clinical narrative: Information has been received from SPMSD, as part of business agreement, on 07-AUG-2014. This literature marketed report as received from a physician refers to a 6 year old female patient. The patient with no medical history and a normal ocular examination 1 year ago in 2012 was referred to herpes zoster (HZ) in VI distribution. On presentation, she had new-onset vesicular rash and left eyelid swelling. The left upper eyelid, forehead, and scalp were affected, and the trash was noted to respect the midline. There was no history of chickenpox or recent exposure, but she did receive a dose of (Oka/Merck) VARIVAX (lot # unknown, dose unknown) 5 years before presentation on 30-NOV-2007 and a booster 1 year before the presentation on 09-AUG-2011. The referring pediatrician had made a diagnosis of shingles, and the patient was placed on a 10-day course of acyclovir 200 mg 3 times daily and cimetidine 300 mg 3 times daily, and acetaminophen as needed for pain. On initial examination in our clinic (8 days after the onset of rash), visual acuity measured 20/20 OD and 20/30 OS. The intraocular pressure measured 14 mm Hg OD and 15 mm Hg OS. External examination revealed mild left upper eyelid swelling and almost completely resolved left-sided facial rash in the VI distribution of the trigeminal nerve. By the time she presented to our clinic, there were no active vesicles, and we were unable to obtain fluid for polymerase chain reaction analysis. There was mild conjunctival injection on the left but no anterior chamber inflammation or corneal findings. The patient returned after 9 days for follow-up (17 days after the onset of rash) with a decrease in vision in the left eye to 20/70. On examination of the left cornea, there were 3 avascular opacities with diffuse borders that appeared to be white blood cells in the superficial stroma. The right eye was unaffected. The patient was started on topical prednisolone acetate 1% (PRED FORTE, ALLEGRA) 1 drop 4 times daily OS and continued on oral acyclovir 200 mg 3 times daily. One month later, the stromal opacities had improved somewhat but vision was still 20/60. Amblyopia therapy was initiated by patching the right eye 1 hour per day. Vision improved to 20/40 with improvement of the stromal opacities. The patient was then lost to follow-up, presenting again after 4 months with decreased vision after running out of prednisolone drops, which she was reportedly using 4 times daily until this time. She developed reactivation of the keratitis with a decrease in vision to 20/60. Prednisolone drops were then increased to 8 times daily and gradually tapered to 3 times daily over 5 months. At the last visit, 1 year after the original presentation, the visual acuity had improved to best corrected visual acuity (BSCVA) 20/20 OS, and the slit-lamp examination findings were stable, with only mild subepithelial haze. The steroid continues to be tapered. Unfortunately, because of our patient's late presentation, the clinic was unable to confirm whether reactivation was caused by the wild-type or Oka strain varicella-zoster virus. Both are known to cause reactivated HZ in the vaccinated pediatric population with potentially harmful sequelae. The Oka strain cannot be ruled out, given recently published reports of reactivation an immunocompetent children. Our patient did not have a history of repeated or chronic infectious suggestive of immune deficiency. A normal complete blood count was performed in 2011. She did not follow up for additional testing after being referred to an immunologist. Regardless, it is important to remember that no vaccine is 100% effective, and even with the introduction of the 2-dose regimen, HZ remains a legitimate health concern in both immunocompromised and immunocompetent pediatric populations. At the time of reporting, the outcome of the events were unknown. Action taken was not applicable. The relationship between the events and (Oka/Merck) VARIVAX were related. A copy of the published article is attached as further documentation of the patient's experience. Additional information has been requested.