Age: 8.0
Sex: M
Vaccine: VARCEL, VARCEL
Symptoms: CSF lymphocyte count increased, Headache, Herpes zoster, Lumbar puncture, Lymphocyte count decreased
Clinical narrative: Information has been received from a physician concerning a normal healthy 8-year-old male, with no significant medical history who on 09-FEB-2000 was vaccinated in the left deltoid with a dose of VARIVAX (Oka/Merck) (lot # 632051/1367J). On 09-FEB-2000 the patient developed herpes zoster and was hospitalized. The site of vaccination correlated with the site of subsequent herpes zoster. The patient developed herpes zoster "right around the area of vaccination" with VARIVAX (Oka/Merck). On 13-FEB-2000 the patient developed meningitis and was hospitalized. The patient had an extensive history and physical examination at the time of his herpes zoster and meningitis, including an immunologic work-up. All testing was within normal limits and there was no evidence of immunosuppression. On an unspecified date the patient completely recovered from his experiences with no sequelae. It was reported in an unblinded manuscript entitled: Herpes zoster with meningitis caused by two different varicella vaccine-associated varicella-zoster virus strains. "Ten cases of viral meningitis attributed to varicella vaccine have been reported with a long interval after vaccination. Only six of these cases were confirmed to have VZV in cerebrospinal fluid, and only two contained confirmed vaccine-strain VZV; one case occurred in an immunocompromised child. We report a case of laboratory-confirmed VZV with meningitis caused by Oka/Merck strains of VZV in an immunologically normal child who had received varicella vaccine." Case Report "A healthy 8-year-old boy without prior atypical infections or recognized exposure to varicella, who had received one dose of varicella vaccine at one year of age, developed one painless pruritic papule on his left shoulder. The rash evolved into multiple small vesicles over the next two days. The third day his physician diagnosed HZ with possible bacterial superinfection. The following day he developed severe headache, meningismus, photophobia, vomiting, and low grade fever, and was hospitalized. Neurologic exam was normal. Computerized tomographic (CT) imaging without contrast was normal. CSF contained lymphocytes with normal glucose and protein. CSF PCR for VZV was positive. Blood count and serum chemistries, including liver function tests, were normal with the exception of borderline lymphoenia (1180/mm3). He received acyclovir (15 mg/kg intravenously every 8 hours) for two days. After near-resolution of symptoms he was discharged with analgesics, but without antiviral therapy." "During the ensuing three days he had a recrudescences of severe headache and photophobia, without fever, but with intermittent somnolence, and was rehospitalized. Neurologic exam remained normal. Multiple left arm and shoulder lesions were scabbed without erythema, and there were no extradennatomal lesions. Repeat lumbar puncture revealed persistent lymphocytic pleocytosis without hypoglycorrhachia, but with elevated protein. Blood count and serum chemistries, including liver enzymes, were normal. CT imaging, without contrast, did not show parenchymal abnormalities or meningeal enhancement. CSF PCR for HSV, enterovirus, and VZV were negative, as were viral and bacterial cultures. Quantitative immunoglobulins, T and B cell subsets, and HIV testing were normal. VZV-specific IgM and IgG EIA-antibodies in serum were strongly positive. Intravenous acyclovir was administered (15 mg/kg every 8 hours) for 7 days during hospitalization. All symptoms resolved within 48 hours. He was discharged to receive valacyclovir for one week. Liver enzymes were elevated in the hospital (AST 99, ALT 94), but were normal one week after discharge. Two weeks after discharge he was asymptomatic and had a normal physical examination. " Result "CSF specimens from each hospitalizatoin indicated that DNA from a variant of Oka/Merck strain VZV was present in both tubes of CSF obtained on the third day of illness, but could to be detected in CSF five days later. Scabs from three individual skin lesions contained an identical variant of Oka/Merck strain VZV, which was different from the variant present in the CSF. Variants from both sites carried three of the four most stable vaccine markers in ORF62 (105705, 106262, 107252), but the variant in skin lesions was wild-type at the fourth marker (108111). The variant obtained from CSF carried the vaccine marker at position 108111, but differed at two other vaccine-associated markers (94167, 101089), and exhibited atypical transversion mutations at these loci that differed from known vaccine and wild-type genotypes. DNA from none of the samples displayed mixed markers at any of the vaccine-associated SNP positions, suggesting that each variant was clonal at its respective site. Standard genotypic analysis indicated that both strains were genotype I, consistent with Oka vaccine." Discussion "This is one of only three laboratory-confirmed cases of meningitis caused by Oka/Merck strain VZV in children, and only the second in an immunocompetent child. This case indicates that vaccine-related HZ meningitis can be severe, with clinical and laboratory features similar to those observed with HZ and meningitis caused by wild type VZV, and that recrudescence of symptoms can occur in the absence of VZV in the CSF. The medical history of the child, and limited immunological assessment, indicates that he was immunocompetent. This is also indicated by the timely healing of skin lesions and disappearance of VZV DNA from CSF by day 8 of disease, whereas some immunosuppressed patients have delayed clearance of VZV from CSF. The illness was not associated with clinical or imaging evidence of encephalitis and he recovered completely." A lot check has been initiated. Additional information has been requested. A copy of the published literature article will be provided, when available, as further documentation of the subject/patient experience.