A healthy 37-year-old man presented with a pruritic rash, chills, and body aches for three days. He was afebrile and had scattered vesicles on an erythematous base, on his trunk and extremities (Figs. 1 and 2). He reported never having chickenpox but had received two doses of the varicella vaccine at age 20. He worked at a nursing home where a resident had recently developed shingles. Vesicular fluid PCR testing was positive for varicella zoster, consistent with chickenpox.
Fig. 1.
Vesicular rash on trunk.
Fig. 2.
Vesicular rash on back.
The varicella zoster virus (HHV-3) can cause two forms of disease—primary infection (varicella, or chickenpox) and a reactivation disorder (herpes zoster). This patient developed chickenpox almost two decades after being vaccinated. Each year after vaccination, the rate of breakthrough varicella increases.1 A meta-analysis found approximately 80% effectiveness for a single dose in preventing varicella disease of any severity and over 99% effectiveness in preventing severe disease (defined by > 500 lesions, complications requiring medical care, hospitalization, or death). Two doses increased the mean effectiveness to approximately 92 to 93% in preventing breakthrough varicella of any severity.2, 3 This patient was treated with a 7-day course of valacyclovir and was advised to stay home from work for two weeks.
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References
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