Varicella infection following vaccination in a pediatric kidney transplant recipient

Abstract

The live attenuated varicella-zoster virus (VZV) vaccine prevents varicella infection in immunocompetent children. Such live viral vaccines have been historically avoided in children after solid organ transplantation and bone marrow transplant, due to concerns for disseminated vaccine-induced disease and/or poor immunogenicity in immunocompromised recipients. As reviews emerge reporting safety and adequate immune response in immunosuppressed patients, however, some are considering a revision of this guideline to allow at least a subset of transplanted children to receive live viral vaccines after transplantation. Although the situation is admittedly rare, here we report a case of disseminated VZV infection in a 4-year-old kidney transplant recipient after he was inadvertently administered the live attenuated MMRV vaccine. | C A S E REP ORTA 4-year-old boy presented to the emergency department (ED) with a chief complaint of rash 16 months after receiving a living-related kidney transplant. He had a history of end-stage kidney disease (ESKD) secondary to kidney dysplasia and had received both peritoneal dialysis and hemodialysis prior to transplant. His post-transplant course had been complicated by recurrent Clostridioides difficile colitis, which had responded well to treatment. He had no history of rejection. The patient had developed a papular pruritic rash on his back and anterior chest 12 days prior to presentation, which spread to his nose and left cheek over the course of a week. The lesions at first seemed consistent with molluscum contagiosum, which the patient had been diagnosed with in the past. He presented to the ED due to increased fussiness thought to be due to pruritus. He had not been febrile at that time. His only known sick contact was a younger sibling with an upper respiratory tract infection with no associated rash. On examination, the patient was noted to have a crusted vesicular rash Abstract Live viral vaccines have historically been avoided in children after solid organ transplantation. Multiple reports of safety and immunogenicity, largely in the pediatric liver transplant population, have led to a reconsideration of this recommendation.Here, we report the case of a 4-year-old boy who inadvertently received the live attenuated MMR-varicella vaccine (MMRV) at a routine well-child visit 16 months after receiving a living donor kidney transplant. This was not known until after he was admitted with rash and documented disseminated varicella infection 5 weeks later. He was treated with intravenous acyclovir followed by oral therapy and recovered fully. This case and its discussion illustrate what is still unknown about the risk-to-benefit ratio of live viral vaccination in any individual transplant recipient. Criteria to determine which patients should receive these vaccines should be evaluated before their use after transplant becomes routine, and all recipients and their families should be counseled to have a low threshold to seek medical care for any febrile illness or rash after live vira...

Late-Onset Concurrent Infection of Vaccine Strain VZV and HSV-1 after Varicella Vaccination in a Child with Natural killer T Cell Deficiency

“…4,10 In contrast to wild VZV infections, death from proven vOka infections is exceedingly rare. 9,15,16 In a systematic review published in 2017, 14 (7%) of the 192 solid organ transplant patients who received varicella vaccine developed vaccine-associated varicella, but no deaths were reported. 15 Only six fatalities have been reported, all in immunocompromised children in whom overwhelming varicella followed vaccination.…”

“…9 15 16 In a systematic review published in 2017, 14 (7%) of the 192 solid organ transplant patients who received varicella vaccine developed vaccine-associated varicella, but no deaths were reported. 15 Only six fatalities have been reported, all in immunocompromised children in whom overwhelming varicella followed vaccination. 16 HSV/VZV coinfected patients had more head region and less genital region involvements.…”