Sex: F
Vaccine: VARCEL
Symptoms: Nasal congestion, Pain, Patient isolation, Pemphigoid, Pemphigus
Clinical narrative: This literature marketed report has been received from the authors of the literature article concerning to a 3 year old female patient. On an unknown date, the patient was vaccinated with varicella virus vaccine live (oka/merck) (manufacturer unknown) (lot#, expiration date, dose and route not reported) for immunization. She was documented with the varicella/zoster virus (VZV) immunizations. The patient's mother first noticed skin lesions in the patient's antecubital regions and on the backs of her legs. At that time, the lesions were relatively mild with some pruritus. The patient was seen by her pediatrician and diagnosed with eczema, which was treated with hydrocortisone cream. Over the course of the following week the lesions developed blisters, which eventually became erosions, spreading to her face, legs, arms, and buttocks. Her trunk was relatively spared. The patient was admitted to an outside hospital with a diagnosis of extensive impetigo and was treated with intravenous antibiotics. The patient showed mild improvement and was discharged home on clindamycin. In the interim, the patient visited an adult dermatologist who agreed with the diagnosis of impetigo and added prednisone (manufacturer unknown) and a topical steroid. Despite the prescribed regimen, the lesions continued to worsen with intense itching. The patient remained afebrile throughout the course of her illness. The patient had mild nasal congestion but no other symptoms. The patient with eczema presented to the emergency department with 2 week history of a progressive skin rash. On arrival to the emergency department, the patient's temperature was 37 Celsius degree (98.6 degrees fahrenheit), pulse 111 beats/minutes (bpm), respirations 20 breaths/minutes, and blood pressure 126/77 mm Hg. The physical exam was normal except for diffuse areas of large, confluent, pruritic vesicles on erythematous bases and painful open erosions that were worse on her face, lower extremities and buttocks. The lesions were in various stages of development. No lesions were present on mucus membranes, palms, soles, or perineum. The initial laboratory results were noncontributory including a normal white blood cell count of 10 240/mm3 but mildly elevated platelets at 407000/mm3. The patient was admitted to the general pediatric ward. The umbilicated circular lesions on her face were felt to be most suggestive of herpes simplex virus (HSV) and a diagnosis of eczema herpeticum with secondary impetiginization from Staphylococcus aureus or group A beta-hemolytic streptococci was suggested. Acyclovir was started for empiric treatment of suspected eczema herpeticum, and bacterial superinfection was initially treated with vancomycin and ceftriaxone. The patient's pruritus was controlled with diphenhydramine and hydrocodone was given for pain. However, the dermatology was also consulted and offered a differential diagnosis ofbullous dermatosis including: bullous impetigo, liner immunoglobulin A (IgA) bullous disease, pemphigus, foliaceous, bullous pemphigoid of childhood, eczema herpeticum, and secondarily impetiginized VZV. Aerobic and anaerobic bacterial cultures were obtained and fluid from vesicles was sent for HSV-DFA (direct fluorescent antibody) and VZV-PCR (polymerase chain reaction). The aerobic bacterial culture returned positive for Staphylococcus aureus. Antimicrobial therapy was changed to intravenous cefazolin. By hospital day 3, the lesions had shown marked improvement, including crusting and disappearance. The vesicle PCR returned positive for VZV, and the DFA was negative for HSV. The patient was transferred to a negative pressure room as recommended for VZV infection control. Due to the patient's positive immunization for VZV vaccine, an human immunodeficiency virus (HIV) test was obtained and was negative. On hospital day 4, the patient was deescalated (recovering) to oral acyclovir and cephalexin and discharged home. Discussion The patient clinical diagnosis was difficult because the skin lesions had a centrifugal distribution as contrasted with the centripetal distribution of chicken pox vesicles and the patient had received VZV vaccine. She could have been one of those rare children who do not respond to the vaccine. The reporter speculated that VZV may have been able to cause this eczema herpeticum-like reaction. The outcome of no respond to vaccine and positive VZV was unknown. Upon internal review, eczema herpeticum was determined to be medically significant.