Continued Surveillance for Herpes Zoster is Essential Following Varicella-Zoster Virus Live Attenuated Vaccine

A new case report of a young girl published in Le Infezioni in Medicina emphasizes the importance of monitoring young patients for herpes zoster following the administration of the varicella-zoster virus live attenuated vaccine.¹

The CDC recommends 2 doses of the varicella-zoster vaccine for children, adolescents, and adults who have never had the virus and were never vaccinated. Children should receive the first dose between 12 and 15 months of age and a second dose at 4 to 6 years of age.²

According to the case study authors, herpes zoster is rare in children and almost always occurs in those who are immunocompromised and who have had a primary intrauterine infection or varicella in their first year of life.¹ Herpes zoster can also develop after vaccination, with an incidence of approximately 14 cases per 100,000 people annually, according to the study authors.¹

The case examines a 4-year-old immunocompetent girl who received 1 dose of the varicella-zoster virus live attenuated vaccine at 15 months. Following the vaccination, she developed a painful vesicular rash on her right arm, despite no known contact with varicella. A screening was negative for varicella IgM antibodies, she was fully immunized for other illnesses, and she was otherwise healthy.¹

Physicians prescribed a combination of fusidic acid and betamethasone as a topical cream, but she returned 2 days later with further lesions, severe pain, and a headache. She was diagnosed with herpes zoster and treatment with acyclovir and analgesics was prescribed for 10 days, along with eosin lotion. The child’s lesions began crusting after 2 days and her pain subsided. She recovered completely without any further complications.¹

According to the authors, earlier studies in leukemic children found that the risk of herpes zoster is decreased by re-exposure to the varicella zoster virus, either through vaccination or a close exposure.¹ This case, however, is the first patient younger than 5 to have developed herpes zoster since the universal varicella zoster vaccine was introduced in Greece in 2004, where the researchers are based.¹

Notably, the researchers said their case demonstrates that even 1 dose of the live attenuated vaccine can precipitate an occurrence of herpes zoster, even among immunocompetent patients. They added that further research should examine the effect of vaccination of the epidemiology of the herpes zoster virus, particularly where the economic status of patients is changing quickly in response to the coronavirus disease 2019 pandemic.¹

REFERENCES

• Pelekouda E, Papagiannis D, Tsiaousi I, Maltezou H. Herpes zoster after vaccination with one dose varicella vaccine to a 4-year-old child. Le Infezioni in Medicina; December 1, 2019. https://www.infezmed.it/media/journal/Vol_27_4_2019_15.pdf. Accessed October 5, 2020.
• CDC; Chickenpox (Varicella) Vaccines. Updated September 9, 2020. https://www.cdc.gov/vaccinesafety/vaccines/varicella-vaccine.html#:~:text=CDC%20recommends%20two%20doses%20of,age%204%20to%206%20years. Accessed October 5, 2020.