Posters

Live attenuated vaccines are contraindicated in immuno-compromised individuals as they may develop fulminant disease

Poster Details

First Author: S.Maqsood UK

Co Author(s):    S. Ahmad              

Abstract Details

Purpose:

We report the case of a 70-year old gentleman on long-term immuno-suppression following a renal transplant who received the live herpes zoster vaccine. Over the following 6 weeks he developed disseminated varicella infection with widespread dermal involvement and bilateral ophthalmic involvement.

Setting:

St. Paul's Eye Unit, Royal Liverpool University Hospital

Methods:

A 70-year old gentleman presented to Eye Casualty with a one-month history of bilateral generalised lid swelling and persistent ocular irritation On examination, he had bilateral swollen and erythematous upper lids with no obvious vesicular lesions and no dermatomal distribution of the swelling but a dendritiform lesion of the left cornea. At follow-up one month later, he described a two-week history of reduced vision in the left eye and a persisting headache. However, both eyes had now developed a florid anterior uveitis and the intraocular pressure was elevated in the right eye. The corneal swabs were positive for VZV and negative for HSV. He was commenced on frequent topical prednisolone 1% eye drops to both eyes and topical cyclopentolate 1%. Although the uveitis in both eyes was much improved, both corneas now had large atypical dendritiform lesions. . In view of these on-going atypical signs and bilateral disease, his general history was reviewed. He was taking oral immuno-suppression for a kidney transplant. In September 2013, two months before initial presentation to the Eye Casualty, he had received the live attenuated vaccine for Herpes Zoster (Zostavax, Sanofi-Pasteur-MSD).

Results:

. In view of the HZV positive PCR result, bilateral atypical herpetic corneal and anterior chamber disease, skin signs consistent with herpetic disease, a continuous headache persisting despite analgesia and immuno-suppression, it was felt that the gentleman had developed systemic disseminated Herpes Zoster infection post-vaccination. In particular, the concern was that he was at risk of HZV related encephalitis. He was referred to Infectious Diseases and following discussion with the renal physicians, he was commenced on systemic acyclovir.

Conclusions:

Lessons learnt 1. VZV is a live vaccine that should not be given to patients who have had solid organ transplants and remain on immuno-suppression treatment. 2. Immuno-suppressive treatments may alter the patient's response to infection and so patients may have atypical infectious presentations such as uveitis in a ‘white' eye. 3. VZV may cause sight-threatening and life threatening complications. 4. Immuno-suppressed patients should be treated with systemic antivirals if they develop potentially life-threatening or sight-threatening complications. FINANCIAL INTEREST: NONE