Age: 1.23
Sex: M
Vaccine: HBHEPB, VARCEL
Symptoms: Activities of daily living impaired, Blood immunoglobulin G, Blood immunoglobulin M, Chest X-ray normal, Differential white blood cell count normal
Clinical narrative: Information has been received from a physician concerning an 11 year old male patient with no chickenpox in history and no drug allergies, who on 05-NOV-1999 was vaccinated with a first dose of COMVAX (OMPC). There was no concomitant medication. The patient experienced zoster-like rash in April 2008, September 2008 and April 2009, dermatomes 3, 4, 5, and 6 on the left side were involved. He currently had 5-10 lesions and pain. It was also reported that the patient had a 4 episode of herpes zoster in April 2008, September 2008, April 2009 and on 13-APR2010. The rash appeared on April 2008, and did not occur at the site of injection post vaccination. It was papulovesicular rash type with 8 lesions in the left arm and back. The herpes zoster was with dermatome of C4-C6. The patient had pain (8 grades) and no fever. The patient had recent exposure to chickenpox or herpes zoster at school 3 weeks ago (approximately at the beginning of April, 2010). The patient had concurrent medication on TYLENOL and codeine. No a direct fluorescent antibody was done. Specimen was obtained on 20-APR-2010 and sent to the lab on 20-APR-2010. Varicella IgG was positive. The patient recovered from the prior 3 episodes. At time of reporting, the patient had not recovered from the fourth episode. Follow up information has been received from a health care professional who indicated that the first sample was from the patient's left arm and the second sample was from the patient's back. The samples were collected on 20-APR-2010 from saliva and a swab from an unrooted lesion. On 21-APR-2010, the specimen arrived at the laboratory, it was noted that there was no saliva received. It was reported that the VZV DNA and the B-globin DNA were not amplified. The results showed an inadequate specimen, negative for B-globin, no strain I.D. Follow up information has been received from physician indicating that the patient had no crusted lesions this week (refer to the week from 26-APR-2010 to 29-APR-2010) at the moment. The physician was trying for the patient to see a dermatologist to consider biopsy. The patient had recovered. Follow up information received from a nurse indicating that they started seeing the patient in their office in 2002, therefore he was not vaccinated at their practice. Follow up information received from a physician who is a Pediatric Infectious Disease Fellow, regarding this 10 year-old male child. The doctor could not confirm if the patient received VARIVAX (Merck) or COMVAX (MSD). It was reported that the child's recurrent rashes were all on the patient's left side ranging from dermatomes C1 to C4. While the location was similar for each episode, the presentation of the rash was not. While the location was similar for each episode, the presentation of the rash was not. She noted that the appearance of the lesions was different with each episode. Some lesions had an erythematous base, but they were not typical or classic varicella or zoster-like rashes. She said to her knowledge, the patient was not diagnosed with herpes zoster. She said she had not diagnosed him with herpes zoster, nor had there been any confirmatory lab or other diagnostic testing to confirm herpes zoster. Again, she noted that the presentation of the rash was different in each occurrence and that if this was varicella-related, that it was not a typical presentation. She noted it was possible that this might not even be VZV-related. It was reported that this atypical presentation does not necessarily mean it is associated with the vaccine. It was noted this child has had 5 episodes of rash on the following dates: First episode occurred in April 2008; Second in September 2008; Third on 06-April-2009; Fourth in August 2009; and Fifth on 13-April-2010 - Note: prior to the 5th episode, the child had a school exposure to chickenpox. The patient's pediatrician treated him with acyclovir for the first 3 episodes. During the third episode, the pediatrician consulted with the physician, who saw the patient for the first time on 16-APR-2009; however, by the time she saw the patient, he was at the end of the third episode and most of the lesions were crusted so she did not see the rash at the time of active lesions. The physician also noted that the fourth episode in August 2009 resembled poison ivy, so they did not treat the patient with acyclovir for this rash occurrence. The most recent outbreak was 13-APR-2010, and the patient was not treated with acyclovir for this episode either, as they wanted to try to obtain lesion samples for diagnostic testing and did not want to affect potential viral load by using acyclovir or other antiviral medication. She also noted that the lesions from the April 2010 episode were quite small and were papulovesicular lesions, which was likely why the specimen they submitted to the VZVIP was inadequate for PCR testing. The physician reported his medical history was unremarkable, though of note is that he is a twin. His twin sister was vaccinated on the same day as the patient (05-NOV-1999), and she has not had any reported rash or problems. The patient's mother has a history of varicella at the age of 4, and had no known varicella exposure during her pregnancy. With respect to an immunologic work-up, the reporter said the child had not had a comprehensive evaluation, but had had the following: CBC with differential, which was normal and did not reveal any lymphopenia; a chest x-ray, which ruled out a mediastinal mass and lymphoma; and an HIV screen which was negative. It was also reported that his "IgG was positive and IgM was negative, which indicated the patient responded to the vaccine." Follow up information received from another physician stated that the patient had recovered so she wasn't able to collect a sample. She explained that should he develop another rash/case of shingles that he would be seen by a dermatologist for evaluation and to also obtain the samples. The physician explained that the patient was referred to the Infectious Disease Group because of the new requirement for State that all children receive 2 doses of VARIVAX (Merck). She explained that just after the requirement was passed, the patient was seen in the office with a "rip-roaring" case of shingles that started on 06-APR-2009. At this point she referred him to Infectious Disease to determine if he needed a second dose of VARIVAX (Merck) or could receive a waiver because of his shingles experience. The physician explained that the patient's shingles involved his entire left arm and he was not able to go to school for 2 weeks. She explained that he has been a patient of her practice for years, however, her office did not vaccinate him with VARIVAX (Merck). To her knowledge he did his first dose of VARIVAX (Merck) prior to switching to her practice. She indicated that she would attempt to clarify this information. Additional information has been requested.