Sex: F
Vaccine: VARCEL
Symptoms: Herpes zoster cutaneous disseminated, Horner's syndrome, Intraocular pressure test normal, Miosis, Nuclear magnetic resonance imaging brain normal
Clinical narrative: This literature marketed report has been received from the authors of a published literature article and refers to a 52-year-old female patient with a history of varicella infection in childhood. It was stated that she had no other significant past medical history. The patient was not taking any medications and had received no other vaccinations within the past year. A detailed reviewof the patient's systems was unremarkable. On an unknown date, the patient was vaccinated with VARIVAX, lot # N017698, expiration date: 09-JUN-2019 (dose, route of administration and anatomical location were not provided) for varicella prophylaxis. The authors stated that it was unclear why this 52-year-old patient received VARIVAX and not ZOSTAVAX, especially given her history of varicella infection in childhood. On an unknown date, three days after receiving the VARIVAX (also reported as 3 weeks after vaccination), the patient experienced a burning vesicular and erythematous rash on her lower back and left leg. The patient initially presented to her dermatologist who diagnosed her with disseminated cutaneous herpes zoster and began treatment with valacyclovir, 1 g three times per day, and gabapentin, 300 mg three times a day, for pain. On an unknown date, seven days later, the patient presented to her ophthalmologist with rightsided ptosis and a miotic pupil. The anisocoria was greater in darkness than in light. Consistent with Horner's syndrome, instillation of 1% apraclonidine dilated the miotic pupil and reversed the ptosis of the right eyelid, however it had no effect on the normal pupil as one may expect.1 There was no facial anhidrosis, T1 radiculopathy, or lymphadenopathy noted on examination to further localize the lesion. The patient had a negative human immunodeficiency virus (HIV) test and a normal white blood cell count. The results of pupil exam, performed on an unknown date ,were following: right eye - 3.5mm  in dark and 2 mm in dark; left eye - 4.5 mm in dark and 2.5 mm in light; and after instillation of apraclonidine 1% in both eyes: right eye - 5.5 mm  in dark and 5 mm in dark; left eye - 4.5 mm in dark and 2.5 mm in light. Margin to reflex distance was following: right eye 2 mm, left eye 4mm and after instillation of apraclonidine 1% in both eyes: right eye 4.5 mm, left eye 4.5 mm. The visual acuity was 20/20 in each eye, extra ocular motility was full and intraocular pressure was normal in both eyes. The cornea was clear as was the iris without trans-illumination defects. There was no anterior chamber reaction or evidence of vitritis. Funduscopic examination of the right eye revealed two small retinal haemorrhages along the superior arcade in the absence of retinitis. Further work-up for Horner's syndrome revealed an unremarkable computed tomography (CT) scan of the chest, magnetic resonance angiography (MRA) of the head and neck, and magnetic resonance imaging (MRI) of the brain. Given the presence of disseminated cutaneous herpes zoster in the absence of a lesion along the sympathetic chain, this patient's Horner's syndrome was presumed to be secondary to herpes zoster infection. On an unknown date, over the course of the following month, the rash and the retinal haemorrhages resolved. The ptosis and anisocoria also resolved on an unknown date, over the course of the following two months. The authors considered the events to be related to the vaccination with VARIVAX as patient's Horner's syndrome and retinal haemorrhages began after developing a disseminated herpes zoster infection after the varicella vaccination.