Age: 78.0
Sex: F
Vaccine: VARZOS
Symptoms: Excoriation, Gram stain negative, Impetigo, Rash, Rash erythematous
Clinical narrative: Information has been received from a 78 year old female with a history of cardiac disorder, diabetes pure hypercholesterolaemia, hypothyroidism, congestive heart failure, essential hypertension, coronary atherosclerosis, angioplasty with stent placement (on 13-JUL-2007) and triple bypass surgery and no drug reaction/allergies history reported, who on 23-JAN-2008 was vaccinated with a first dose of ZOSTAVAX vaccine(Oka/Merck) (route and administrating site, Lot number not reported). Concomitant therapy included hydrochlorothiazide (manufacturer unknown) 12.5 mg daily, PLAVIX 75mg daily, LIPITOR 40mg daily, metoprolol 12.5mg AM and PM, SYNTHROID 100 mcg daily, isosorbide 60mg daily, Aspirin 325mg daily, Osteo-Renewer 600 mg bid, calcium carbonate (-) OSCAL D 500 bid; stool softener 2 tablets daily; LEVEMIR 8-12 UNITS DAILY; HUMALOG inject 6 units tid; multi-vitamin 1 tablet daily, nitroglycerin 0.4mg 1 tablet sublingual every 5 minutes as needed, up to 3 per episode, TYLENOL 650 mg every 4 hours as needed and MSD 25mg daily. Two weeks later, the patient developed a rash. The rash started on her lower back with three spots (one large, one medium, and one small). The patient went to see her dermatologist, by the time she got to the office her back had all these little red dots resembling a chicken pox or shingles type rash. Then the patient had skin eruptions all over her body. On 04-Feb-2008, serum glucose test was performed. The patient had skin eruptions all over her body. On 04-Feb-2008, Serum glucose test was performed. The result was 293 mg/dl (normal range 70/100 mg/dl). On 20-MAR-2008 skin tissue gram stain was performed. No organisms and WBC;s were seen; a skin tissue culture was done, the result indicated that staphylococcus and acinetobacter lwoffii growth. The physicians diagnosed her as having a minor staph infection and provided her with a medication for treatment, but that did not work. The patient did not know the name of the manufacturer or name of that product. The rashes developed into massive quarter-sized eruptions all her body. The patient has seen two dermatologists and one infectious disease doctor who have not helped her. On 08-APR-2008 the patient was diagnosed as dermatitis. On 08-MAY-2008 the patient was seen by the physician. Her blood pressure was 150/56 mmHg. Papular rash was noted on her back, right and left arm. These lesions were slightly raised, and hyperpigmented, with some excoriation, didn't quite look like typical zoster lesions. Other physical examination was normal. The physician was not  quite sure what the etiology of the rash was. The clear history and association with the zoster vaccine would suggest that this could be an atypical zoster presentation. This was a live vaccine, and could potentially cause a reactivation in an immunosuppressed patient. This patient was diabetic. However, it would be very atypical to have this cyclic pattern of lesions coming and going, and no development of neuralgic symptoms if she had gone this long without antizoster therapy. The physician started ACYCLOVIR and treated as if a zoster syndrome, but would also refer to dermatology for consideration of a skin biopsy and other etiologies of the rash. On 09-JUN-2008 the patient returned to clinic for management of her skin rash. Her blood pressure was 84/54 mmHg. Papular rash was noted on the back, right and left arm, chest, abdomen, scalp, shins. Most notable were those on her hands and wrist. These lesions were slightly raised, erythemaous, resolved lesions were hyperpigmented), with some excoriation. Other physical examinations were normal. The patient stated that after "cure" she was left with a hyperpigmaneted area. The patient denied ever suffering from pain or discomfort from the lesions. The patient had seen numerous specialists at outside hospital, who had diagnosed with infectious eczema, impetigo and staph infection. The patient was treated with topical FLUCINOLONE, but the lesions had no completely gone away. The patient not iced that the lesions appeared, lasted for about a week and then another batch of lesions appeared again. The physician indicated that although these onset of symptoms coincided with ZOSTAVAX vaccine (Oka/Merck) immunization, and this was a live vaccine, and could potentially caused a reaction in an immunosuppressed patient he was not convinced that was what was ongoing. While the patient was immunecompromised from  diabetes and age, she had no known high level immuncompromise (transplant, HIV/AIDS, steroid or other immunemodulation medication, cancer etc. It would be very atypical for zoster. In addition the patient was status post a therapeutic trail with ACYCLOVIR which didn't change the outcome. The patient was given BENEDRYL for itching as needed. On 20-JUN-2008 a skin biopsy was performed.  The diagnosis was: subacute dermatitis with scattered eosinophils. The Patient's minor staph infection and pruritic rash, dermatitis persisted.  The patient was enrolled in the Varicella Zoster virus identification Program  to identify if VZV is present and if it is present to identify present to identify if it is associated with the wild-type VZV strain or with the OKA/Merck vaccine VZV strain. The sample of the lesion was collected on 11-JUL-2008. The source and the site of specimen were not reported. The PCR result for the specimen from lesion was negative. On 24-JUL-2008 the patient reported "the skin eruptions had returned. They were on by back, face, legs, arms and now on my face and in my hair. I had a follow up visit with the physician next week." No further information is available.