Age: 2.0
Sex: F
Vaccine: VARCEL
Symptoms: Dermatitis bullous, Drug ineffective, Infection, Laboratory test abnormal, Pruritus
Clinical narrative: Information has been received from a school nurse concerning a 7 year old female with a history of congenital bilateral dysplasias, a renal transplant, and immunosuppression who on 8/31/98 was vaccinated with a dose of varicella virus vaccine live. Over the weekend, sometime between 9/24/03 and 11/5/03, the patient developed breakthrough varicella and was hospitalized for four days (also reported as three days). The patient missed two weeks of school after the hospitalization. The patient is currently back in school and has recovered. Additional information was received from a registered nurse who indicated that the reason for the patient's transplant surgery in January 2000 was congenital. The patient was born with bilateral dysplasias. The nurse indicated that there was no relation between the patient's transplant and vaccination. Follow up information was received from the school nurse who indicated that the patient was admitted to a hospital on 10/25/03 with varicella. The patient was treated with acyclovir and was discharged on 10/28/03. Follow up information, including a discharge summary, was received from the registered nurse who indicated that on 10/24/03 the patient developed varicella and was admitted to the hospital for IV acyclovir for four days. The discharge summary indicated the admitting diagnoses were varicella and end stage renal disease with immunocompromise. Procedures included IV fluids and acyclovir. The history of present illness indicated that patient had a past medical history significant for end stage renal disease of unknown etiology after being born with one kidney and renal dysplasia, status post renal transplant in January 2000. She presented to the emergency room on 10/25/03, with a one day history of a rash. She reported noting a spot on her back. The mother noticed at the time that the rash had spread to her back. Her rash was erythematous, vesicular, and pruritic. She denied any nausea, diarrhea, fever, headache, cough, or mental status changes. She had normal activity and normal by mouth intake. Positive sick contacts with varicella at school. The hospital course indicated that due to the patient's immunocompromised state, it was decided to admit the child and treat her varicella with IV acyclovir. The patient's home medications were continued except for her mycophenolate mofetil which was restarted on 10/27/03 at 25 percent of the original dose. Daily basic metabolic profiles and CSA's were monitored. Mycophenolate mofetil dose was adjusted accordingly. The patient was started on acyclovir on 10/26/03, on a renal dose. Followed creatinine Q AM and made adjustments accordingly. The patient continued to do well throughout her hospital stay and continued to have good by mouth intake and good urine output and appropriate stool output. On the morning of 10/28/03, the patient was feeling well and had no complaints. It was noted that the patient recovered on 10/28/03. All of her vesicular rash had healed except for two lesions on the feet. The mother was very appropriate and knowledgeable and it was felt at that time that it would be safe to discharge the patient home. The patient was to follow up the next Wednesday in the clinic. She was also to be followed on telephone the coming Friday to see how everything was healed.The patient was being sent home on by mouth acyclovir on a renal dose. Her mycophenolate mofetil was then at 175mg every 12 hours. The patient was told to return if she had increasing lesions, fever, change in mental status or anything concerning the parents. The patient's blood ura nitrogen and creatinine were initially elevated, but on the day of discharge, they were down to 28 and 1.0. Cyclosporin level was then 187. The discharge diagnoses were varicella resolving and end stage renal disease in immunosupprants currently. No further information is expected. The school nurse also reported breakthrough varicella in children after therapy with varicella virus vaccine, a case of varicella in a teacher, and a case of breakthrough varicella in a second grade child. It was noted that the CDC and state health department were involved in surveillance.