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Write-up: This case was reported in a literature article and described the occurrence of varicella-zoster virus meningoencephalitis in a 55-year-old male patient who received DTPa. Co-suspect products included Meningococcal vaccine unknown, 10PN-PD-Dit. Haemophilus influenzae type b vaccine. Hepatitis A vaccine, Hepatitis B vaccine and Polio Trivalent Inactivated. The patient''s past medical history included chickenpox (during childhood with no identified exposure to the virus prior to the event), leukemia myelogenous and allogenic bone marrow transplantation therapy (He was reported to have done well after then transplant and that he had only suffered a chronic limited skin graft-versus-host disease that had not required continued immunosuppressants). Previously administered products included melphalan, fludarabine, alemtuzumab and tacrolimus. Concomitant products included BACTRIM Adult and acyclovir. On an unknown date, the patient received DTPa vaccine at an unknown dose, Meningococcal vaccine at an unknown dose, Pneumococcal vaccine at an unknown dose, Haemophilus influenzae type b vaccine at an unknown dose, Hepatitis A vaccine at an unknown dose, Hepatitis B vaccine at an unknown dose and Inactivated polio vaccine at an unknown dose. On an unknown date, 244 days after receiving DTPa vaccine, Meningococcal vaccine, Pneumococcal vaccine, Haemophilus influenzae type b vaccine, Hepatitis A vaccine, Hepatitis B vaccine and Inactivated polio vaccine, the patient experienced varicella-zoster virus meningoencephalitis (serious criteria death and GSK medically significant), cerebrospinal leukemoid reaction (serious criteria death), seizures (serious criteria GSK medically significant), headache and vesicular skin rash. The patient was treated with antivirals for systemic use and medication unknown (Unspecified Treatment). On an unknown date, the outcome of the varicella-zoster virus meningoencephalitis and cerebrospinal leukemoid reaction were fatal and the outcome of the seizures, headache and vesicular skin rash were unknown. The reported cause of death was acute meningoencephalitis and leukemoid reaction. An autopsy was performed. It was not reported if the reporter considered the varicella-zoster virus meningoencephalitis, cerebrospinal leukemoid reaction, seizures, headache and vesicular skin rash to be related to DTPa vaccine, Meningococcal vaccine, Pneumococcal vaccine, Haemophilus influenzae type b vaccine, Hepatitis A vaccine, Hepatitis B vaccine and Inactivated polio vaccine. Additional details provided: This case was reported in a literature article and it described the occurrence of a varicella-zoster virus meningoencephalitis in a male subject who was at least 55 years old at the time of the event and had been vaccinated with unspecified DTP, meningococcal, pneumococcal, Haemophilus influenzae b, hepatitis A and B and inactivated poliovirus vaccines (manufacturers unknown). The subject had a medical history of chicken pox during childhood with no identified exposure to the virus prior to the event. He had not been vaccinated for measles or herpes zoster virus. He also had a previous history of acute myelogenous leukaemia with diploid cytogenetics that been treated with allogenic haematopoietic transplantation using a fully matched brother when he was 54 years old. He was reported to have done well after the transplant and that he had only suffered a chronic limited skin graft-versus-host disease that had not required continued immunosuppressants. The conditioning for the transplant had consisted of melphalan, fludarabine and alemtuzumab. In addition to that, tacrolimus had been used for graft-versus host disease prophylaxis. Concurrent medications at the time of the event included BACTRIM and acyclovir. No further information on his medical history, concurrent medical conditions or concomitant medication was provided. On an unspecified date, 1 year after the allogeneic haematopoietic transplantation, the subject received unspecified DTP, meningococcal, pneumococcal, Haemophilus influenzae b, hepatitis A and B and inactivated poliovirus vaccines for (dosages, administration routes and sites unknown; batch numbers not provided). On an unknown date, 1 year and 8 months after the transplantation, the subject presented with headache, seizures and vesicular skin rash. This is a serious case as the outcome was fatal. Diffuse meningeal enhancement without focal lesions was revealed on magnetic resonance imaging. Cerebrospinal fluid analysis showed xanthochromic fluid with a red blood cell level of 252/cmm, white blood cell level of 576/cmm and glucose level of 159 mg/dL. Two cerebrospinal fluid cytology specimens contained monocytic cells that resembled blasts morphologically with delicate chromatin, moderate gray-blue cytoplasm with vacuoles and azurophilic granules, as well as the occasional mitosis. The corresponding flow cytometry showed 21% and 24% mature monocytes without immunophenotypic aberrancy. No myeloblasts or cells of the prior leukemic immunophenotype (CD341, CD1171, CD331, CD131, CD14-) were identified by flow cytometry. There was no nucleated red contamination. No cytogenetics studies were performed on the cerebrospinal fluid. Blood tests showed a blood glucose level of 154, a white blood count level of 10 400/mL (normal range 4.5-11), a haemoglobin of 13.2 g/mL (normal range 12-16), mean corpuscular volume of 94.7 fl (normal range of 82-100), mean corpuscular haemoglobin of 91 pg (normal range 27-34), platelets level of 166 000/mL (normal range 150-400) with a differential of 85% neutrophils, 7% lymphocytes, 7% monocytes and 1% basophils. Blood flow cytometry showed no blasts and 7% mature monocytes with no aberrancy. The morphologically immature cells seen in the cerebrospinal fluid were not present in his blood, which according to the authors, suggested that these cells originated in the cerebrospinal fluid. Cerebrospinal fluid and blood polymerase chain reaction for varicella-zoster virus revealed $g1.0 x 108 and 327 000 copies (Vira core) respectively. Treatment consisted of antiviral treatment and supportive care. The outcome of the event was fatal. Autopsy results indicated subacute/chronic meningoencephalitis with no acute leukaemia involving the central nervous system. The authors did not comment on any causal relationship between the vaccines received by the subject and the events. The authors concluded that "When considering acute myelogenous leukaemia relapse in the cerebrospinal fluid of an allogenic haematopoietic transplantation subject, flow cytometric and microbiology studies should be considered to rule out a reactive process. Disseminated varicella-zoster virus is the most frequent late infection of allogenic haematopoietic transplantation".
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