Issue Number 28
November 5, 1998
UNPROTECTED PEOPLE: Stories of
people who have
suffered or died from vaccine-preventable diseases
- Story #4: THREE FATAL VARICELLA CASES
IN UNVACCINATED
YOUNG WOMEN
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Three fatal varicella cases in young adult women
were reported to CDC by state health departments during January-April 1997. All three
women were susceptible to varicella, unvaccinated, and infected by exposure to
unvaccinated preschool-aged children who had contracted
varicella. These three cases appeared in the MMWR, May 16, 1997, vol. 46, no.19 and are
reprinted below.
NOTE: There are approximately 100 deaths and 10,000 hospitalizations from
varicella each year in the United States. The ACIP recommends that all susceptible
children (12 months of age and older) and all susceptible adults be vaccinated. Please
recommend varicella vaccine to your susceptible patients of all ages.
Case 1: Death of a 23-year-old woman
On January 19, 1997, a 23-year-old woman in good health had onset of a classic varicella
rash. In early January, her 2- and 5-year-old unvaccinated children had had varicella. On
January 22, she had onset of shortness of breath and hemoptysis. When she was
admitted to a local hospital on January 23, a chest radiograph indicated diffuse
alveolar density consistent with varicella pneumonia, and treatment
was initiated with oxygen and intravenous acyclovir. Her condition worsened, and she
required intubation several hours after admission. Because of increasing respiratory
distress, she was transferred to a referral hospital where treatment continued with
oxygen, antibiotics, and intravenous acyclovir.
On January 31, her rash became hemorrhagic, and
she developed disseminated intravascular coagulation (DIC) and renal failure, followed by
progression to multiple system failure; she died on February 2. Varicella zoster virus was
cultured from skin lesions and from a tracheal aspirate.
Case 2: Death of a 25-year-old woman
On March 11, 1997, a 25-year-old woman in good health had onset of a classic varicella
rash, fever, and headache. Her 4-year-old unvaccinated child had had onset of a varicella
rash on February 23. On March 12, the woman had onset of cough, and on March 13, shortness
of breath. On March 14, she sought care at a local emergency department (ED) because of
increasing respiratory difficulty and confusion. Chest radiograph indicated bilateral
infiltrates consistent with varicella pneumonia, and arterial blood gases indicated
hypoxemia. Varicella encephalitis and pneumonia were diagnosed; she was admitted to the
hospital, and treatment was initiated with oxygen and intravenous acyclovir.
Four hours after admission, her respiratory
difficulty increased, and she required intubation. On March 15, a computerized tomography
of the brain revealed severe, diffuse cerebral edema, and she developed renal failure and
coma. On March 16, she was transferred to a referral hospital for renal dialysis; an
electroencephalogram indicated absence of electrical brain activity, and repeat chest
radiographs indicated diffuse infiltrates. She died on March 17.
Case 3: Death of a 32-year-old woman
On April 3, 1997, a 32-year-old woman with Crohn's disease sought medical evaluation at a
local ED because of onset of abdominal and back pain. On March 7, therapy was initiated
with 40 mg prednisone daily for an exacerbation of her Crohn's disease. By April 3, her
steroid therapy had been tapered to 20 mg prednisone daily. On physical examination, she
had mild, generalized abdominal tenderness with no specific signs or abdominal guarding.
She was afebrile, and a white blood cell (WBC) count was normal. A benign abdominal
syndrome was presumptively diagnosed, and she was discharged.
Her symptoms persisted, and on April 4, she sought medical evaluation at the office of her
health-care provider. Findings on physical examination were unchanged. Although an
abdominal radiograph, abdominal and pelvic ultrasounds, and a WBC count were normal,
because of her underlying medical condition, she was referred for surgical consultation.
On April 5, the abdominal pain persisted, and she returned to the ED for evaluation. A WBC
count was 15,000/mm3 (normal: 3200-9800/mm3), and she was admitted to the hospital.
Diagnoses of colitis and ileitis with possible perforation and intraabdominal abscess were
considered, and treatment was initiated with broad-spectrum antibiotics. On physical
examination, a maculopapular, vesicular rash with crusted lesions was observed on her
trunk, head, and neck.
Varicella was presumptively diagnosed, and she
was placed in isolation. The patient reported that she had had onset of a mild macular,
nonpruritic rash on her back on April 3 and that she had been exposed on March 12 and 13
to her 4-year-old unvaccinated niece with varicella. On April 6, the vesicles became
hemorrhagic, and she began bleeding from intravenous sites. She rapidly developed
hypotension and DIC, and died from shock the same day. On autopsy, evidence of viral
inclusion bodies in multiple organs was consistent with varicella, and varicella was
determined to be the cause of death.
To download the MMWR issue which contains these case reports as
well as a detailed editorial note about the recommended strategies
for preventing varicella, click here:
http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00047618.htm
CLICK ON THE FOLLOWING LINKS FOR MORE DATA ON THE IMPORTANCE OF VARICELLA VACCINATION!
FIVE MORE VARICELLA-RELATED DEATHS are reported in the fall/winter 1998-99 issue of
"NEEDLE TIPS." To read these five stories, which are entitled, "Unprotected
people: Five varicella- related deaths that could have been prevented," click here:
http://www.immunize.org/nslt.d/n20/story20.htm
"VACCINATE, DON'T VACILLATE! Varicella kills 100 people each
year in the U.S. What are you waiting for?" This article by Walter A. Orenstein, MD,
Assistant Surgeon General, Director, National Immunization Program, Centers for Disease
Control and Prevention, appears in the fall/winter 1998-99 issue of "NEEDLE
TIPS." To read this article, click here:
http://www.immunize.org/catg.d/2058vac.htm
CDC ANSWERS VARICELLA VACCINE/DISEASE QUESTIONS ON ITS WEBSITE
Visit the National Immunization Program's website to view and/or download over 50
questions and answers on varicella vaccine written by CDC experts for clinicians.
www.cdc.gov/nip/Q&A/clinqa/var.htm
CHICKENPOX ISN'T JUST AN ITCHY, CONTAGIOUS RASH! To download the Immunization Action
Coalition's camera-ready, copyright free, CDC-reviewed brochure for your patients on
varicella vaccine/disease, click below:
English web version:
http://www.immunize.org/catg.d/p4070chi.htm
English camera-ready (PDF) version:
http://www.immunize.org/catg.d/p4070chi.pdf
Spanish web version:
http://www.immunize.org/catg.d/p4070_01.htm
Spanish PDF version:
http://www.immunize.org/catg.d/p4070-01.pdf |
