Case and Research Letters
Disseminated Herpes Zoster After Varicella Vaccination in a Healthy Boy
Herpes zóster diseminado posvacunal en un niño sano
J.M. Rueda
, M. Feito-Rodríguez, D. Nieto, R. de Lucas-Laguna
Corresponding author
Servicio de Dermatología, Hospital Universitario La Paz, Madrid, Spain
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"apellidos" => "Arias" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731016303040" "doi" => "10.1016/j.ad.2016.02.021" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731016303040?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219017301476?idApp=UINPBA000044" "url" => "/15782190/0000010800000006/v1_201706300050/S1578219017301476/v1_201706300050/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Disseminated Herpes Zoster After Varicella Vaccination in a Healthy Boy" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">To the Editor:</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "587" "paginaFinal" => "588" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.M. Rueda, M. Feito-Rodríguez, D. Nieto, R. de Lucas-Laguna" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "Rueda" "email" => array:1 [ 0 => "joserc88@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Feito-Rodríguez" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Nieto" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "de Lucas-Laguna" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario La Paz, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Herpes zóster diseminado posvacunal en un niño sano" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 730 "Ancho" => 975 "Tamanyo" => 60673 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Scattered vesicles in the dorsal region.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The incidence of herpes zoster (HZ) is 42 cases per 100 000 people per year. Infection in children is very rare. The varicella vaccine offers 90% protection against chickenpox and nearly 100% protection against severe cases.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Immunization against varicella was initially expected to cause a decrease in the incidence of HZ. However, the vaccine virus can cause a latent infection that later manifests as HZ. Recent studies have also demonstrated that the risk of HZ in children who have had natural varicella infection is significantly higher than in vaccinated children with no history of chickenpox.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Description</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 6-year-old boy came to our hospital for assessment of pruritic lesions and pain predominantly in the lower left limb. The patient had received a single dose of the varicella-zoster virus (VZV) vaccine at the age of 15 months. Physical examination revealed vesicles grouped on an erythematous base. The lesions followed a metameric distribution on the medial aspect of the left thigh (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Other scattered lesions were observed on the contralateral lower limb and the lumbar region (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Complete blood count and biochemistry profile were normal except for mild lymphopenia (1.91<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/μL [normal values: 2.70-12.60]). VZV serology was positive for immunoglobulin G anti-VZV antibody and polymerase chain reaction of a smear from one of the vesicles was positive. After treatment with oral aciclovir at a dose of 250<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span> every 8<span class="elsevierStyleHsp" style=""></span>hours and follow-up after 4 days, clear improvement was observed in the lesions and the pain, with the alteration having disappeared in the course of treatment.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Since 1998, there have been several reports of HZ in children after vaccination. Molecular biology techniques have been used to differentiate between wild-type VZV and the vaccine strain of the virus (Oka).</p><p id="par0020" class="elsevierStylePara elsevierViewall">The estimated incidence of HZ in vaccinated children varies widely between studies, between 262.1 cases per 100 000 person-years by natural infection and 93.3 cases per 100 000 person-years after vaccination.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,4</span></a> This incidence may be underestimated due to underdiagnosis associated with unfamiliarity with HZ or with the low incidence of the entity in children and the atypical nature of postvaccination cases. Cases of HZ caused by the vaccine strain of the virus exhibit clinical differences with respect to cases caused by wild-type VZV; this could lead to a lower consultation rate in the first group. Among other differences, postvaccination HZ lesions tend to be smaller and less painful, with fewer vesicles, and the lesions predominantly appear on the lumbosacral dermatomes.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> In our case, however, the form of presentation was considerably different and atypical, as the patient was a child with disseminated lesions and intense pain in the affected metamere.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Given the greater susceptibility of children with leukemia to developing HZ, studies have been carried out in this population to assess the incidence of this complication. However, it is important to note that routine VZV vaccination is not recommended in immunocompromised patients because the vaccine contains a live attenuated virus. In children with leukemia, the incidence of HZ was 3 times higher in those who had had natural varicella infection than in those who had received the vaccine.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Age at vaccination could be an important factor influencing the appearance of postvaccination HZ because immunogenicity is lower at younger ages. Reactivation of the Oka virus is more frequent in vaccinated children with low anti-VZV titers.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> These data are consistent with evidence that suggests that varicella infection in the first year of life increases considerably the risk of HZ during childhood. This might be due to the fact that immunity levels are lower in children who contract varicella at a younger age.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> The time to manifestation of HZ after contact with the virus is also related to the age at which contact occurs. The mean duration in children between exposure to varicella and development of HZ has been estimated at 4.12 years, and significantly shorter in children diagnosed with varicella before age 2 years.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">One factor that appears to increase the risk of HZ after vaccination against varicella is the appearance of exanthema after administration of the vaccine. The relative risk of HZ in vaccinated children has been found to be 5.75 times greater in children who develop a vaccine-associated skin rash. According to one hypothesis, the skin lesions could allow the virus to enter the cutaneous nerves and establish a latent infection. The lower incidence of HZ after vaccination could be due to the fact that the attenuated varicella vaccine is less able to access the sensory nerves.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, we present a case of disseminated HZ in a boy with a history of incomplete vaccination against VZV. Although this complication is described in the literature, no increase in incidence after vaccination has been observed. Incomplete vaccination probably led to a waning of immunity that favored the development of HZ.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of Interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rueda JM, Feito-Rodríguez M, Nieto D, de Lucas-Laguna R. Herpes zóster diseminado posvacunal en un niño sano. Actas Dermosifiliogr. 2017;108:587–588.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 732 "Ancho" => 975 "Tamanyo" => 69664 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Vesicles grouped in a metameric distribution on the left thigh.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 730 "Ancho" => 975 "Tamanyo" => 60673 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Scattered vesicles in the dorsal region.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The current status of live attenuated varicella vaccine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 17 | 30 |
| 2024 October | 76 | 62 | 138 |
| 2024 September | 76 | 38 | 114 |
| 2024 August | 137 | 73 | 210 |
| 2024 July | 149 | 54 | 203 |
| 2024 June | 124 | 27 | 151 |
| 2024 May | 134 | 36 | 170 |
| 2024 April | 112 | 34 | 146 |
| 2024 March | 105 | 32 | 137 |
| 2024 February | 87 | 34 | 121 |
| 2024 January | 88 | 40 | 128 |
| 2023 December | 121 | 19 | 140 |
| 2023 November | 169 | 30 | 199 |
| 2023 October | 136 | 32 | 168 |
| 2023 September | 134 | 29 | 163 |
| 2023 August | 153 | 18 | 171 |
| 2023 July | 161 | 42 | 203 |
| 2023 June | 121 | 22 | 143 |
| 2023 May | 159 | 31 | 190 |
| 2023 April | 129 | 29 | 158 |
| 2023 March | 131 | 33 | 164 |
| 2023 February | 119 | 37 | 156 |
| 2023 January | 89 | 44 | 133 |
| 2022 December | 101 | 58 | 159 |
| 2022 November | 63 | 35 | 98 |
| 2022 October | 97 | 26 | 123 |
| 2022 September | 85 | 34 | 119 |
| 2022 August | 92 | 36 | 128 |
| 2022 July | 100 | 25 | 125 |
| 2022 June | 108 | 24 | 132 |
| 2022 May | 116 | 28 | 144 |
| 2022 April | 121 | 38 | 159 |
| 2022 March | 107 | 47 | 154 |
| 2022 February | 132 | 25 | 157 |
| 2022 January | 164 | 37 | 201 |
| 2021 December | 107 | 49 | 156 |
| 2021 November | 139 | 46 | 185 |
| 2021 October | 123 | 56 | 179 |
| 2021 September | 119 | 40 | 159 |
| 2021 August | 127 | 35 | 162 |
| 2021 July | 118 | 32 | 150 |
| 2021 June | 87 | 28 | 115 |
| 2021 May | 102 | 49 | 151 |
| 2021 April | 231 | 85 | 316 |
| 2021 March | 114 | 38 | 152 |
| 2021 February | 123 | 24 | 147 |
| 2021 January | 69 | 21 | 90 |
| 2020 December | 73 | 22 | 95 |
| 2020 November | 57 | 25 | 82 |
| 2020 October | 43 | 16 | 59 |
| 2020 September | 51 | 22 | 73 |
| 2020 August | 69 | 27 | 96 |
| 2020 July | 26 | 29 | 55 |
| 2020 June | 41 | 28 | 69 |
| 2020 May | 20 | 10 | 30 |
| 2020 April | 19 | 16 | 35 |
| 2020 March | 24 | 14 | 38 |
| 2020 February | 3 | 0 | 3 |
| 2019 May | 1 | 0 | 1 |
| 2019 April | 3 | 0 | 3 |
| 2019 February | 2 | 0 | 2 |
| 2019 January | 1 | 0 | 1 |
| 2018 December | 3 | 0 | 3 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 17 | 0 | 17 |
| 2018 September | 7 | 0 | 7 |
| 2018 February | 44 | 4 | 48 |
| 2018 January | 49 | 2 | 51 |
| 2017 December | 53 | 14 | 67 |
| 2017 November | 41 | 10 | 51 |
| 2017 October | 45 | 8 | 53 |
| 2017 September | 42 | 13 | 55 |
| 2017 August | 41 | 19 | 60 |
| 2017 July | 57 | 28 | 85 |
| 2017 June | 18 | 15 | 33 |
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