Age: 1.17
Sex: M
Vaccine: MMRV, VARCEL
Symptoms: Neutrophil count decreased, Nuchal rigidity, Nucleated red cells, Pain, Polymerase chain reaction positive
Clinical narrative: varicella-zoster virus (VZV) meningitis; This literature marketed report has been received from the authors of a published literature article, titled as stated below and refers to a 7-year-old male patient. His past history included febrile seizures at age 13 months.  On an unknown date, at age of 14 months, the patient was vaccinated with his first dose of varicella virus vaccine live (oka/merck) (VARIVAX) for prophylaxis (exact dose, route, anatomical location, lot# and expiration date were not reported). On an unknown date at age of 26 months, he experienced febrile seizures. On an unknown date, at age of 49 months, he was vaccinated with measles, mumps, rubella and varicella (oka-merck) virus vaccine live (PROQUAD) (exact dose, route, anatomical location, lot# and expiration date were not reported) for prophylaxis.  On an unknown date, he experienced erythematous rash about 4 cm in diameter over the right knee. At a medical clinic, poison ivy was diagnosed and oral prednisolone was prescribed at a daily dosage of 20 mg for 7 days (0.8 mg/kg/day). Cytokine inflammatory profiles in the CSF patient's sample was analyzed. The 10 most elevated cytokines in patient's CSF samples included: interferon gamma (75.76), interleukins: IL-1RA (184.63); IL-6 (90.57), IL-8 (4034.30), IL-10 (75.39), and IL-17F (348.68); chemokines CCL2 (616.79), CXCL9 (81.16), and CXCL10 (1178.58); as well as G-CSF (55.79) (units not provided for all).   On an unknown, 17 days after, he developed a headache, followed a few hours later by low grade fever. Next day, his headaches worsened, and he began to vomit. Vomiting continued over the next 24 h whenever his parents attempted to feed him. When the vomiting persisted into the second day, he was admitted to a local hospital for intravenous (IV) hydration. After spending one night at the local hospital, he was transferred to a medical center. On admission, the child was in obvious pain. His physical examination did not disclose any rashes or abnormalities in major organ systems. Although the neurology examination was difficult to perform, he had mild nuchal rigidity but no focal neurological abnormalities. His non-contrast head computerized tomography (CT) imaging was normal. His initial laboratory testing included the following values: erythrocyte sedimentation rate (ESR): 14 mm; C-reactive protein (CRP): 0.5 mg/L; white blood cell count = 4000/mm3 with 1790 neutrophils, 1130 lymphocytes, and 380 eosinophils all per mm3. His hemoglobin was 12.2 gm/dL; aspartate aminotransferase /alanine aminotransferase (AST/ALT): 20/30 units/L and his urinalysis was normal. His cerebrospinal fluid (CSF) was hazy with a glucose of 50 mg/dL, total protein of 60 mg/dL, and nucleated cell count of 544 cells/mm3 with mainly lymphocytes. A multiplex meningitis/encephalitis polymerase chain reaction (PCR) was positive for both varicella zoster virus (VZV) and human herpesvirus 6 (HHV6). Because the preliminary diagnosis was VZV meningitis (Herpes zoster meningitis), treatment with acyclovir, intravenous (IV) at 30 mg/kg/day was initiated. His VZV-specific IgM and IgG antibody titers detected by immunofluorescence were positive at titers of 1:4 and 1:64, respectively. Because the Before meningitis panel had a positive HHV6 signal and the metagenomic next-generation sequencing (mNGS) assay detected HHV7 sequences but no HHV6 sequences, testing for both HHV6 and HHV7 antibodies was performed. The patient had detectable IgG antibodies to both HHV6 and HHV7 at a titer of 1:16. The IV acyclovir was stopped after 4 days, when the child was markedly improved and his headaches resolved. He was discharged on a regimen of valacyclovir (500 mg three times daily) for 10 more days. The child was seen several times during the 18 months post discharge. His recovery from meningitis was complete.   The relatedness between the event and suspect vaccines was considered as related as the authors reported that meningitis was caused by the live varicella vaccine virus. The relatedness between the event and prednisolone was considered as related as it was concluded that ingestion of an oral corticosteroid burst 34 weeks before onset of vaccine meningitis may be a risk factor and treatment with a prednisolone burst at a relatively high dosage likely allowed latent vaccine virus to reactivate.  Literature report:   A copy of the published article is attached as further documentation of the patient's experience.  This is one of three cases derived from the same literature article (cross referenced with MARRS# 2112USA005730 and 2007USA012025).; Sender's Comments:  US-009507513-2112USA005730: US-009507513-2007USA012025: