Sex: M
Vaccine: VARZOS
Symptoms: CSF red blood cell count, CSF white blood cell count increased, Cellulitis, Central nervous system lesion, Confusional state
Clinical narrative: Vaccine Strain herpes zoster (HZ) ophthalmic and meningoencephalitis; Vaccine Strain herpes zoster (HZ) ophthalmic and meningoencephalitis; 11-year-old boy vaccinated with VZV vaccine; Literature Report.  This literature marketed report as received from the authors of a published literature article, titled as stated above, and refers to a healthy, fully immunized, immunocompetent 11-year-old boy. His medical history, concurrent conditions and concomitant therapies were not reported.  On an unknown date, the patient was vaccinated with zoster vaccine live (ZOSTAVAX) subcutaneous injection, administered for prophylaxis (dose, vaccination scheme, strength, lot number, expiration date, vaccine injection site and route of administration were not provided) (product administered to patient of inappropriate age).  On an unspecified date, the patient presented for outpatient care with acute onset left facial pain and rash. On the second day of illness (DOI), he was diagnosed clinically with herpes zoster (HZ) and prescribed oral acyclovir. The rash failed to improve, and he re-presented febrile to 38.9 Celsius degree on DOI 4, with a well-circumscribed beefy erythematous rash composed of confluent vesicles over the left maxillary region, nose, left eye, and forehead. Oral acyclovir was changed to intravenous (IV) infusion. Varicella-zoster virus (VZV) was detected from blood and vesicle fluid by a molecular laboratory developed test using commercially available reagents. On DOI 6, he developed headache, confusion, sleepiness, vomiting, and photophobia. A diagnostic lumbar puncture was performed, and cerebrospinal fluid (CSF) was collected. CSF was colorless, with 58 white blood cells (WBC)/mm3 (9% segmented neutrophils, 87% lymphocytes, 4% monocytes) (ref. 04 WBC/mm3, 1 red blood cell (RBC)/mm3 (ref. 05 RBC/mm3), glucose 55 mg/dL (ref. 3775 mg/dL), and protein 57 mg/dL (ref. 1260 mg/dL). Testing of CSF using a multiplexed molecular panel detected VZV DNA. Bacterial cultures from CSF and blood were negative. Erythrocyte sedimentation rate (ESR) was 23 mm/h and C-reactive protein was 1.0 mg/dL. Complete blood count and comprehensive metabolic panel remained within normal limits. He received 10 days of intravenous acyclovir (45 mg/kg/day q8h) and 7 days of IV clindamycin for clinical diagnosis of superimposed cellulitis. An ophthalmologic evaluation noted a pinpoint lesion in the marginal limbic area, consistent with keratitis, without dendritic lesions or retinal involvement. Keratitis resolved after 3 days of erythromycin ointment, without topical antivirals. Over the course of his weeklong hospitalization, he demonstrated significant improvement of his vesicular rash, with crusting of lesions. He remained hemodynamically stable on room air. After DOI 7, neurologic symptoms resolved. Immunologic studies revealed normal IgG, IgM, and IgA levels, positive VZV IgG, and negative VZV IgM. Laboratory analysis of lymphocyte enumeration showed normal levels of B and NK cells, but low CD8 and CD4 T cell counts. Forster resonance energy transfer polymerase chain reaction (PCR) assays were performed on the CSF sample at the CDC National VZV Laboratory, which confirmed the VZV vaccine strain (vOka). The patient was notable for trigeminal HZ with ophthalmic involvement (ophthalmic herpes zoster) and concurrent meningoencephalitis (herpes zoster meningoencephalitis); laboratory confirmed by molecular detection of VZV from skin, serum, and CSF samples. On an unknown date, the patient recovered from the events. Repeat lymphocyte enumeration and proliferation assays normalized 6 months later.   The authors considered the events to be related to zoster vaccine live (ZOSTAVAX).   Upon internal review, the events ophthalmic herpes zoster and herpes zoster meningoencephalitis were determined to be medically significant.  A copy of the published article is attached as further documentation of the patient's experience.