Age: 10.0
Sex: F
Vaccine: MNQ, TDAP, VARCEL
Symptoms: Skin lesion, Smear site unspecified abnormal, Ulna fracture, Varicella post vaccine, Varicella virus test positive
Clinical narrative: Information was received from a research assistant from department of pediatrics who provided medical records concerning a 16 year old female who on 19-JUL-2007 received her second vaccination with VARIVAX (Merck) in the left arm (lot number reported as 01250). She had received her first vaccination on 18-DEC-1997 (lot number reported as 09578). On 19-JUL-2007 she also received the following vaccinations: MENACTRA and BOOSTRIX (GlaxoSmithKline). Medical history included otitis media. Dermatology consult on 15-DEC-2012 revealed the following: History of present illness indicated the 16 year old female was admitted for disseminated VZV. She was seen at a dermatology clinic on 13-DEC-2012 at which time she had multiple herpetic vesicles on the left ear and neck. Tzanck smear was positive. She was started on VALTREX 2g by mouth twice daily times one day. The lesions crusted but more lesions appeared in other places. VZV DFA returned positive. It was noted the female had chickenpox vaccination with booster and never had primary varicella. Physical exam revealed well appearing young woman in no acute distress. No conjunctival lesions or erosions/ulcers. Total body surface exam revealed oropharynx clear. Crusted 2-3 mm vesicles in groups in pink base on left neck and ear. Folliculocentric pink capsules on dorsal upper arms and thighs consistent with previous keratosis pilaris. However, also with pink 2-3 mm vesicles/papules scattered on arms, chest, abdomen and medial thighs (new compared to 13-DEC-2012). Impression: progressive disseminated herpes zoster despite VALTREX. The patient reported fatigue, nausea, vomiting, rash and lesions. The dermatologisty indicated the female gave history of recurrent upper respiratory infections, many ear infections as child requiring tympanostomy times two, many episodes of sinusitis as a child, tonsillitis and pneumonia. Her siblings were healthy without these recurrent infections. The patient was never evaluated by immunologist in the past. Under past medical history the following were also listed: recurrent PNA (pneumonia) thought to be associated with posterior mediastinal ganglioneuroma, mediastinal ganglioneuroma resection in 2004, history of low pneumococcal vaccine, polyvalent (MSD) titers in 2005 with adequate response to pneumococcal vaccine, polyvalent (MSD) and again with low titers in 2012 (see MARRS # 1301USA005117). Past surgical history included tonsillectomy in 2008 and septoplasty in 2012. Given dissemination, past varicella vaccination and booster and recurrent upper respiratory infections and pneumonia, the dermatologist recommended immunodeficiency workup. The following were orders: IV antiviral per ID, VZV PCR and culture, allergy and immunology consult and would care with VASELINE. Inpatient medications included acyclovir injection 550 mg in 0.9% NaCL 110 mL intravenous every eight hours for 48 hours. Outpatient medications included acetaminophen with codeine 300mg-30 mg oral every four hours. The research assistant provided the following information: The onset date of the varicella zoster virus was 07-DEC-2012. A VZVIP sample was obtained on 15-DEC-2012. Cerebrospinal fluid (exact date not specified) revealed protein 7.6, red blood cells 4.5, glucose 92 and white blood cells 6.1. Medical records from pediatric/adolescent physician's office listed the following under problem list: posterior mediastinal ganglioneuroma resection (Apr 2004), tonsillectomy (June 2008), viral pharyngitis (02-NOV-1999 and 2003), otitis media (2001, January 2010 and 19-NOV-2011), Strep (27-FEB-2001 and 19-JAN-2003), viral illness (09-FEB-2003), pneumonia (26-APR-2005, September 2005, September 2008 and April 2010), bronchitis (2007), sinusitis (2006, September 2008 and December 2010), right radius/ulna fracture (Apr 2008). All available medical records will be provided up requested. Additional information has been requested.