Age: 10.0
Sex: F
Vaccine: VARCEL
Symptoms: Malaise, Oral pain, Pyrexia, Rash, Rash erythematous
Clinical narrative: Information has been received from a health professional concerning a 10 year old adopted female in excellent health and with no known allergies who on July 8, 2003 at about 03:30, was vaccinated in the left anterior thigh with a first dose of varicella virus vaccine live (lot#645052/0204N). There was no illness at the time of vaccination. It was reported that the patient was completely normal with no history of hypertension, diabetes, cardiovascular disease, asthma etc. She had no history of operations, no pets, no animal exposure, no recent trips to camp or insect infestations. It was reported that there was no outside travel and no close relatives or friends have similar illnesses. The patient's biological mother had a history of obesity, IV drugs use and questionable diabetes. The next week, on approximately July 14, 2003, the patient developed a rash on her face, around her eye and across her nose. She was seen in the office on July 14, 2003 an July 21, 2003 because the rash was getting worse. She was sent to the ER and was admitted to the hospital on July 21, 2003. The nurse said her nose was so bad that it looked like it was going to fall off. it was reported that no tests were taken in the office and prescription drug treatment was required for the experience. No product quality was involved. No other information was available. Additional information from a health professional indicated that the patient was vaccinated because she had not contracted natural chicken pox. She developed a rash on her face that went around her eye and across her nose. The rash continued to get worse and she was sent to the ER and admitted to the hospital. The child was diagnosed with chicken pox, was treated and recovered with minimal scarring left on her face. She could not report on any specific lab work or cultures because the chart was not available at this time. Additional follow up information from a health professional and medical records indicated that, according to the parents, this started out like a sunburn on her nose on July 20, 2003. She ran a low grade fever the previous day, July 19, 2003, and had a temperature of 103.2 on July 20, 2003. She had some white heads that have scabbed up and she had some yellow crusty discharge. The rash was also described as small red bumps on and around her nose, a large scab on the nose, blistering rash over the bridge of the nose and several vesicles on the sides of her nose. Initially there was no rash anywhere else. The patient reported that the rash was a little bit itchy. Flu like symptoms and malaise were also reported. (Onset date unknown) This then spread underneath her eyes. A physician saw the patient on July 21, 2003 and diagnosed "herpes dermatitis" after vaccination. At the office her temperature was 100.2 (also reported as afebrile) The physician reported that she seemed stable so she was started on acyclovir 400mg tabletes QID for 5 days and cephalexin 250mg cap PO QID for 10 days. The flourescen lamp exam was negative and the child was referred to an opthamologist on July 21, 2003. It was reported that the child was diagnosed with a dermatitis irritation im the right eye. She presented for evaluation for possible ocular involvement with herpes zoster. On ocular exam her visual acuity with correction was 20/50 in the right eye and 20/40 in the left eye. Pupil reactions were normal, extraocular movements are full, anterior segment exam showed conjunctival follicles, cornea is crisp, anterior chamber is deep and quiet and there was no conjunctival injection. The conclusion was that there was no ocular involvement of the herpes infection. Artificial tears were recommended for lubrication prn and follow up should the eye become painful or the vision become worse. On July 22, 2003 the mother called with an update and reported that it looked like she had a few more vesicles. The rash started to crust up and she began having headaches. They also reported that the areas had spread to the throat and the child had a sensation of lesions in her mouth. The patient wasn't wanting to drink well and she was complaining that her throat hurt. The patient was referred to dermatology and was then admitted to the hospital for IV antibiotics. The child saw the dermatologist priori to hospitalization. The dermatologist felt this was herpetic or zosteriform dermatitis. It was reported that she sent swabs of the lesions to make sure it was not herpes, but the specimens were adequate. It is unknown where the specimens were sent for analysis. the child was admitted to the hospital on July 22, 2003. on admission, a blood chemistry and hematology were done and were all normal. A blood culture was done and showed no growth for 5 days. She had a large raised yellow hard crusted area on the bridge of her nose. It was on the tip of her nose and several small pink vesicles were lateral to this. On July 23, 2003 she was seen by an infectious disease physician. Review of systems was normal except for a low grade fever, itching at sites, mild headache, enlarged nodes especially on the right and sore throat. Her physical exam was normal except for the rash and lymph nodes. There was a large zosteriform eruption covering the entire nose from side to side, from bridges of teh nose down to the tip of the nose, covering the entire diameter. There are zosteriform mamillated blister-like lesions with herpetiform appearance, mostly coalescent, some discreet and with a black, necrotic dry eschar that is irregular in shape and with very distinct margins covering most of the center of this, over a diamond shaped area of 2-3 cm in either direction. This is not draining and there is no surrounding erythema, induration, areas of cellulitis, etc. The oral cavity is clear without oralthrush or ulcerations. There was a boggy, tender bilateral cervical adenopathy mostly in the anterior chain of the lymph nodes. It was recommended that a HIV test was performed and was negative. The infectious disease physician noted that this was a herpetic or zosterform outbreak following varicella vaccine. She noted that this is not generalized varicella...never the less this could be herpes zoster and that it could also be a primary herpes simplex outbreak. She also reported that she would be aware that the child was at risk for postherpetic neuralgia. She said there was no evidence of secondary soft tissue infection or cellulitis. While hospitalized the patient was initially started on IV acyclovir as well as ceftriaxone sodium. it was reported that cefazolin sodium was also started for further skin coverage. She responded well to the IV acyclovir and all lesions were crusted up so, on July 25, 2003 the patient was in stable condition and was discharged home with a course of acyclovir and cephalexn. She was also instructed to take MBX 1 cc po q 3-4 hrs prn, domeboro soaks twice a day and diphenhydraminne hcl 12.5mg pi q 6 hrs prn. Upon discharge she was alert and active and in no apparent distress. She was well hydrated, drinking well and had no complaints of headaches or mouth pain. Her physical exam was normal except her skin which had lesions on the nose. All vesicles were crusted over and the crust over the bridge of her nose was starting to come off slightly with some hypopigmented areas of skin seen underneath. It was reported that the patient was considered recovered. Additional information has been requested.