Sex: M
Vaccine: VARZOS
Symptoms: Necrotising retinitis, Ophthalmological examination abnormal, Polymerase chain reaction positive, Varicella virus test positive, Varicella zoster virus infection
Clinical narrative: This spontaneous case was received from a health care professional on an unpublished manuscript and refers to a 62-year-old male patient. The patient's concurrent conditions included end-stage liver disease and diabetes mellitus type 2 without retinopathy. Information on patient's medical history and concomitant medications were not reported. It was also reported that the patient did not have other immune-related disorders or frequent infections. On an unknown date (also reported as 7 months ago), the patient was vaccinated with ZOSTAVAX for prophylaxis (dosing details, lot # and expiration date were not reported). On an unknown date, the patient presented with two day history of floaters and blurred vision in the left eye. The patient's vision acuity was 20/60 (units not reported) and intraocular pressure was 16 mmHg. On an unknown date (7 months after vaccination), the patient underwent an unspecified examination which showed inflammation in anterior chamber and vitreous, multiple white retinal lesions and necrosis on presentation in the left eye. Late phase fluorescein angiogram showed late leakage and staining inferonasally corresponding to the area of CMV retinitis in the left eye and a normal appearing angiogram of the right eye. The patient was initially treated with oral valganciclovir and topical difluprednate for presumed cytomegalovirus (CMV) retinitis. On an unknown date, the patient also underwent unspecified blood tests for infectious and inflammatory etiologies which were negative apart from a borderline acute retinal necrosis (ARN). On an unknown date, subsequent polymerase chain reaction (PCR) test of his aqueous humor was positive for varicella zoster vaccine (VZV). The patient was treated with valacyclovir 1 gram 3 times per day which replaced valganciclovir. It was reported that after 10 weeks, his visual acuity improved to 20/50 (units not reported), vitritis resolved and retinal lesions became inactive. The treatment with valacyclovir was decreased to 1 gram daily and topical steroids were tapered. On an unknown date, the patient died from complications of his cirrhosis 6 months following his initial diagnosis of ARN (Hepatic cirrhosis). The patient had recovered from necrotizing retinitis was recovered. The outcome of varicella zoster virus infection was unknown. The causality assessment of the events was not provided. The reporters stated that the patient experienced milder disease and longer latency periods. The longer latency periods might be associated with wild-type virus in ARN due to VZV as well as systemic disease. The reporter stated that immunocompetence might play a role in ARN after VZV vaccination and the patient might have been relatively immune compromised due to end stage liver disease and diabetes. Upon internal review, necrotizing retinitis and hepatic cirrhosis were determined to be medically significant. This is one of the two reports received from the same source. Reported Cause(s) of Death: The patient died from complications of his cirrhosis.