Age: 4.0
Sex: M
Vaccine: MMR, VARCEL
Symptoms: Herpes simplex serology negative, Herpes zoster, Herpes zoster ophthalmic, Insomnia, Irritability
Clinical narrative: Information has been received from a physician concerning a 4 year old patient who was vaccinated with a second dose of VARIVAX (Merck) (lot # not reported) recently. Subsequently the patient experienced zoster (involving the ocular area) and "the case was fairly severe". The patient's outcome was unknown. Follow-up information was received from the physician. It was reported that a specimen obtained from the patient had been sent to confirm the diagnosis of herpes zoster. The physician did not state if the report was confirmed. Additional information has been requested. Follow up information was received on 20-NOV-2008 via a telephone call from the physician. She stated they were interested in submitting a sample for the VZVIP. She explained that the specimen which was a small scab was collected on 29-OCT-2008 and stored at room temperature. It was reported that the patient had improved. He had some healing wounds, but no active wounds. The physician mentioned she had digital pictures of the child's outbreak and would send them in. No further information is available. Follow up information received on 21-NOV-2008 from the physician via medical records concerning an almost 4 year old (pre-school) male patient with no venereal diseases, an allergy to AUGMENTIN (rash), no recent exposure/history to chickenpox, shingles or VZV, and a history of mild eczema, the first dose of a flu shot, fever/mild illness after 2 year old sister had hand foot mouth disease 2 months before his illness, and a bump on his lip (questionable cold sore), who on 31-OCT-2005 was vaccinated with his first dose of VARIVAX (Merck) (lot 646546/0391R, dose not reported) in his left arm. He was also vaccinated with a dose of MMR II (lot 649232/0028R, dose not reported) in his left arm on the same date. It was reported that the patient had no medications prior to onset of herpes zoster. The patient was enrolled in the Varicella Zoster Virus Identification Program to identify if VZV was present and if it was present, to identify if it was associated with the wild type (WT) VZV strain or with the Merck vaccine VZV strain. The sample of the lesion was collected on 29-OCT-2008. The sample was taken from a scabbed lesion on the face. The sample was sent to the laboratory on 20-NOV-2008. The patient was last in his usual state of health on 10-OCT-2008. He started with fussiness, not sleeping well, then approximately on 13-OCT-2008, 1 small red spot on forehead. He complained of pain in left eye. He was due for his 4 year vaccines, but did not have the second vaccination for VARIVAX (Merck). It was reported that the patient did not experience a rash at the site of injection post vaccination or within 42 days of vaccination. On 14-OCT-2008, he developed a swollen painful eye and went to the walk in clinic. He discontinued an unspecified therapy and changed to OMNICET. Rash and swelling progressed until on 15-OCT-2008, he was seen in emergency department. The rash was to his hairline, swollen and painful periorbital skin. He was admitted from 15-OCT-2008 to 21-OCT-2008. Initial treatment included 7 days of Acyclovir IV. On the second day, he was positive for multiple little blisters. On the fourth day, he started to feel better. He was still finishing 2 more days of Clindamycin for total 10 days. He initially was on Vancomycin, then changed to Clindamycin and Infectious Disease was consulted. On 25-OCT-2008, the patient was seen for questionable periorbital cellulitis VZV versus HSV with a prior admit from 15-OCT-2008 to 21-OCT-2008 for VZV reaction in V1 distribution status post vaccination at 12 months old. He was initially treated with 7 days of Acyclovir and was also treated for a possible secondary bacterial infection. Up to 24-OCT-2008, the patient was much better and his activity was better. He was recently adherent to Clindamycin at home. Then last night on 24-OCT-2008 and in AM, increased swelling, redness, complained of light sensitivity. He still had poor appetite, fussing, but no vesicles now. Other systemic symptoms included pain left eye, herpes zoster left face with V1 distribution, and positive stable peripheral corneal involvement. He was admitted on 25-OCT-2008 with recurrence of left V1 erythema, left eye pain, left eye photophobia, left eye conjunctival injection after being home, off anti-virals for 3.5 days. A physical examination revealed a playful, talkative, active patient in no apparent distress. His left eye had mild minimal edema peri-orbitally, no vesicles except hyperpigmented changes from prior lesions. Positive erythema from mid-scalp to "bone." He received daily IV acyclovir followed by twice daily oral acyclovir. The patient was seen on 20-NOV-2008 and was much improved. He still has residual left eye photophobia and healing lesions. He was otherwise well. The patient was vaccinated with the following: 04-JAN-2005, 04-MAR-2005 and 19-MAY-2005 - DTaP-HepB-IPV and pneumococcal vaccine (unspecified). No further information is available. Medical records available upon request.