Sex: F
Vaccine: VARCEL
Symptoms: Pain in extremity, Pallor, Photophobia, Pleocytosis, Polymerase chain reaction positive
Clinical narrative: a case of varicella zoster virus vaccine-associated meningitis;   Information has been received from the authors in a published literature article title as stated above and refers to a 12-year old female. The patient's pertinent medical history, concurrent conditions, or drug reactions/allergies were not provided.  On an unspecified date in 2006, the patient was vaccinated with varicella virus vaccine live (Oka/Merck) (VARIVAX) (dose, strength, route and anatomical location of administration, lot number and expiration date were not reported) as a varicella immunization. The patient was also vaccinated in 2009 with varicella virus vaccine live (Oka/Merck) (VARIVAX) (fully immunized).   On an unspecified date, the patient presented to an urgent care facility with 4 days of acute onset sharp right upper extremity pain and 1 day of rash over the right arm and shoulder.  At urgent care, she was diagnosed with shingles and sent home on a course of valacyclovir (dose and frequency not reported). It was stated that she tolerated one dose of valacyclovir that evening (exact date not provided), but subsequently developed fever to 100.2 grades Fahrenheit, severe headache, photophobia, nuchal rigidity, and mydriasis.  At that point, she presented to the emergency department where her exam revealed a tired-appearing but neurologically intact girl with photophobia and nuchal rigidity and a nonp-ruritic erythematous, blanching maculopapular rash in the C5-C6 dermatome distribution of the right upper extremity. On an unspecified date, her headache and mydriasis had resolved and she denied nausea, vomiting, abdominal pain or altered mental status  On an unknown date, a workup revealed cerebrospinal fluid (CSF) studies concerning for viral meningitis with lymphocytic pleocytosis (63) and elevated protein (units and results not reported). Blood cultures, CSF cultures, and urinalysis were sent, and empiric ceftriaxone and acyclovir were started at an unreported dose. On day 1 of admission, varicella zoster virus (VZV) was detected on meningitis/encephalitis PCR of cerebrospinal fluid; however, serum polymerase chain reaction (PCR) was negative for VZV. Ceftriaxone was discontinued after 48 hours of negative blood and CSF cultures and acyclovir was increased to1500 mg/m2/day.   The patient was discharged on day 4 of admission on a 14 day course of intravenous acyclovir. Following discharge, sequencing assay of the CSF revealed the vaccine strain of VZV as the etiology of her meningitis (herpes zoster meningitis). However, at the reporting time the outcome of the herpes zoster meningitis and was unknown.   The authors concluded that reactivation of vaccine-associated VZV is exceedingly rare in immunocompetent pediatric patients. But, the combination of a dermatomal rash with signs and symptoms of meningitis in a child should lead one to suspect this rare but important cause of meningitis.  Upon internal review, herpes zoster meningitis was considered medically significant.   A copy of the published article is attached as further documentation of the patient's experience.