Disseminated Vaccine Strain Varicella as the Acquired Immunodeficiency Syndrome-Defining Illness in a Previously Undiagnosed Child

Abstract

ABSTRACT. The Food and Drug Administration licensed a live-virus varicella vaccine (Varivax In March 1995, the Food and Drug Administration approved a live-attenuated varicella vaccine for use in healthy individuals 12 months of age and older. The vaccine has been shown to be safe and effective in healthy children and adults, 1,2 as well as in children with leukemia. [3][4][5] The American Academy of Pediatrics does not recommend routine screening of children for human immunodeficiency virus (HIV) infection before vaccination. In addition, routine administration of varicella vaccine is not recommended for all HIV-infected children. 6 Significant morbidity and mortality is caused by varicella-zoster virus (VZV) in immunocompromised individuals, including those infected with HIV. 7-9 Postexposure varicella-zoster immune globulin prophylaxis decreases the likelihood and severity of varicella in high-risk individuals, but the breakthrough rate can be as high as 26%. 4,5 Exposures to varicella are often not recognized, further limiting the utility of postexposure prophylaxis. Immunization, on the other hand, has the potential of establishing permanent immunity. After primary infection in HIV-infected adults, the risk of reactivation remains low well into the progression of acquired immunodeficiency syndrome. These individuals are at risk of developing zoster, but have a relatively low risk of dissemination. 8 This suggests that the immunization of HIV-infected children could prevent primary (wild-type) infection, thereby eliminating viral entry into dorsal root ganglia 3 and subsequent reactivation.Immunization of immunocompromised patients has been limited to children with leukemia and solid tumors following strict guidelines to limit the potential for serious adverse events. 5 Routine immunization of all healthy children carries the potential risk that unrecognized immunocompromised children could be inadvertently vaccinated. Reported here is a 16-month-old, previously undiagnosed, HIV-infected boy who developed dissemination of the vaccine strain of varicella zoster virus after routine immunization. CASE REPORTA previously healthy 16-month-old boy who was admitted to the University of Michigan Mott Children's Hospital with a 5-day history of increasing respiratory distress, fever (101°F), cough, emesis, and lower extremity weakness. In addition, he had a 1-month history of a progressive erythematous papular rash, which began in the groin and upper right thigh progressing to involve the trunk, axilla, and right knee and foot. The rash was associated with a low-grade fever and the patient had recently been refusing to walk for several days. On admission, he had a pulse of 173 beats/min, and a respiratory rate of 24 breaths/min. Weight (9 kg), height (74 cm), and head circumference (45 cm) were all below the fifth percentile. Physical examination was remarkable for oral thrush, diffuse rhonchi, and scattered wheezes, and a confluent macular rash over the trunk and arms. There was also an erythematous zosteriform patc...

Pathogenesis and Current Approaches to Control of Varicella-Zoster Virus Infections

“…The cell-to-cell spread of VZV, which eliminates extracellular circulation of virions, explains why CD4 and CD8 T lymphocytes are more critical for host defense than specific antibodies. Patients who are deficient in innate (37)(38)(39)(40) and/or adaptive (41)(42)(43)(44)(45) cell-mediated host responses are subject to severe VZV infections, which may even be caused by the live attenuated vaccine strain of the virus (vOka). Laboratory studies of VZV cell-mediated immunity (CMI) in adults suffering from varicella have demonstrated that disease severity is positively correlated with viral load and negatively correlated with virus-specific responses of T lymphocytes (46).…”

In Vitro -Selected Drug-Resistant Varicella-Zoster Virus Mutants in the Thymidine Kinase and DNA Polymerase Genes Yield Novel Phenotype-Genotype Associations and Highlight Differences between Antiherpesvirus Drugs

“…However, in rare circumstances in immunosuppressed children who were undiagnosed at the time of vaccination, the vaccine has caused severe infections or disseminated disease that required prompt and prolonged treatment with antivirals (10,17,30,35). A zoster vaccine is also approved by the Food and Drug Administration (FDA) for prevention of HZ in adults 60 years of age and older (19).…”

Disseminated varicella zoster in an immunocompromised patient: A case report

“…In aging adults, or immunocompromised individuals, the body cannot suppress the virus and a reactivation of zoster can present as a widespread rash-referred to as disseminated. The level of the absolute CD4 count can also alter the severity of presentation in the immunocompromised state [6]. When this occurs, the painful lesions are diffuse, at varying stages of development, and affect all parts of the body.…”