Issue Number 38
December 21, 1998
UNPROTECTED PEOPLE: Stories of
people who have suffered or died from vaccine-preventable diseases
- Story #8: FIVE VARICELLA DEATHS THAT
COULD HAVE BEEN PREVENTED
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[The following five stories of varicella-related
deaths appeared in the fall/winter 1998-99 issue of NEEDLE TIPS. We are reprinting them
for IAC EXPRESS subscribers who do not receive NEEDLE TIPS.]
Editors' note: We hear many stories from parents about physicians who are not encouraging
varicella vaccination. We hope that the following reports of deaths secondary to varicella
infection will motivate clinicians to recommend this vaccine for all their susceptible
patients. There are approximately 100 deaths (half of these in children) and 10,000
hospitalizations each year in the U.S. from varicella. These deaths and hospitalizations
are preventable. Please recommend varicella vaccine to your susceptible patients (of ALL
ages).
Cases 1, 2, and 3 below were reprinted from the MMWR, May 15, 1998, vol. 47, no. 18. Cases
4 and 5 were reprinted from Michigan Immunization Update, winter 98, vol. 5, no. 1.
Case 1: Death of a 21-month-old
On February 28, 1997, a previously healthy, unvaccinated 21-month-old boy developed a
typical varicella rash. He had no reported exposure to varicella. On March 1, he was taken
to a local emergency department (ED) with a high fever and was started on oral
acetaminophen and diphenhydramine. On March 3, his primary-care physician prescribed oral
acyclovir. On March 4, his mother noted a new petechial-like rash. The next morning, his
primary-care physician noted lethargy, a purpuric rash, and poor perfusion. He was
transferred to a local ED. Fluid resuscitation and intravenous ceftriaxone were initiated,
but the child continued to deteriorate rapidly, requiring intubation, mechanical
ventilation, and inotropic support with dopamine. Blood cultures were negative for
bacterial pathogens. Laboratory tests indicated disseminated intravascular coagulation and
severe dehydration. Approximately 1.5 hours after arrival at the ED, he was transported to
a tertiary-care center. Within 10 minutes of arrival, he suffered cardiac arrest and died.
The death was attributed to varicella with hemorrhagic complications.
Case 2: Death of a 5-year-old
On December 21, 1997, a 5-year-old unvaccinated boy with a history of asthma was taken to
a local ED with a fever of 104.5 F (40.3 C) and a typical varicella rash in multiple
stages of healing. The child was treated with antipyretic and antipruritic medications and
discharged.
That evening, the boy developed mild dyspnea and was treated at home for a presumed asthma
attack with metered-dose inhalers and one dose of oral prednisone. He returned to the ED
on December 22 with shortness of breath and a 4-hour history of abdominal and leg pain. On
presentation to the ED, one of the patient's siblings had active varicella and another had
recently recovered from varicella. Physical examination revealed numerous chickenpox
lesions, one of which appeared infected. He was
tachypneic, and his extremities were mottled consistent with peripheral septic emboli.
Chest and abdominal radiographs revealed a right pleural effusion, pneumonia, and mild
ileus. Thoracostomy produced pleural fluid containing gram-positive cocci, confirmed
8 hours later to be group A Streptococcus (GAS). A peripheral blood sample revealed
gram-positive cocci. He was admitted to the hospital and treated with intravenous
ceftriaxone, nafcillin, and acyclovir.
After admission, his breathing became labored and his extremities increasingly mottled. He
rapidly developed hypotension, obtundation, and bradycardia. Despite efforts at
cardiopulmonary resuscitation, the child died 5 hours after arriving at the ED. A
post-mortem examination attributed the death to GAS septicemia, pneumonia, and pleural
effusion, complicating varicella infection.
Case 3: Death of a 23-month-old
On December 14, 1996, a previously healthy, unvaccinated 23-month-old boy developed fever
and a typical varicella rash. Approximately 1-2 weeks earlier, his unvaccinated
4-year-old sibling had contracted varicella. He was taken to his physician on December 17
because of persistent fever and cellulitis of the left foot, and he was hospitalized on
December 19 for failure to improve on an unspecified outpatient antibiotic regimen.
Because his condition deteriorated despite intravenous methicillin and ceftriaxone, he was
transferred to a regional hospital on December 21. Sepsis, possible viral
meningoencephalitis, and mild pleural effusion were diagnosed. A cerebrospinal fluid
examination revealed lymphocytic pleocytosis, and blood and urine cultures grew
penicillin-resistant Staphylococcus aureus. Antibiotics were changed to nafcillin
and gentamycin, and intravenous acyclovir was added on December 23. On December 24, the
child developed an aortic insufficiency murmur, and an echocardiogram revealed a 9x9 mm
vegetation on the aortic valve, consistent with bacterial endocarditis. Serial
echocardiograms displayed growth of the vegetation and development of a pericardial
effusion. He was transferred to a cardiac surgery center on December 26. While awaiting
surgery, he developed refractive heart failure secondary to staphylococcal endocarditis.
He became incoherent, probably secondary to a major embolic neurologic event, and died on
January 8, 1997.
Case 4: Death of a 35-month-old
In March 1997, a 35-month-old unvaccinated, previously-well male child presented to the
local hospital emergency room with gastrointestinal bleeding and onset of shock. He was
transferred to a larger hospital and admitted to its pediatric intensive care unit (PICU).
On admission to the PICU the child had a seizure, followed by rapidly progressive
multi-system failure. The child died 2.5 hours after admission. Autopsy determined that
the cause of death was chickenpox and associated complications (causes of death noted in
the hospital medical record were cardiac arrest secondary to profound hypotension,
possible myocarditis, massive gastrointestinal hemorrhage, and varicella infection). This
child had onset of varicella eight days prior to admission (an unvaccinated older sibling
had onset of varicella three weeks prior) and was seen by a physician at that time.
Case 5: Death of a 42-year-old
In early 1997, a 42-year-old male presented to a hospital emergency room complaining of
epigastric pain. A physical exam noted rash consistent with chickenpox. The patient stated
all three of his children had been diagnosed with chickenpox in the previous three weeks.
His previous medical history included severe chronic emphysema and chronic bronchitis,
which was being managed with steroids under a physician's care. During the course of his
hospitalization he developed varicella-related pneumonia and septic shock. The patient
died three days after admission. According to a sibling, the patient was thought to
have had chickenpox in childhood, but this could not be documented.
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which these stories appeared, click here:
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