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Endocarditis attributable to group A beta-hemolytic streptococcus after uncomplicated varicella in a vaccinated child
A L Laskey1, T R Johnson, M I Dagartzikas
1Department of Child Health, University of Missouri, Columbia, Missouri 65212, USA.
Insights
A previously vaccinated child developed severe group A beta-hemolytic streptococcus (GABHS) bacteremia and endocarditis after varicella. This case highlights rare but serious complications of varicella, even after vaccination.
Area of Science:
- Pediatrics
- Infectious Diseases
- Cardiology
Background:
- Varicella (chickenpox) is typically a benign childhood illness, but severe complications can occur.
- A live, attenuated varicella vaccine exists, though its necessity for a generally mild disease is debated.
- Increased recommendations for childhood varicella vaccination are being observed in various states.
Observation:
- A previously healthy 3-year-old, vaccinated against varicella, contracted the illness.
- The child developed group A beta-hemolytic streptococcus (GABHS) bacteremia without apparent skin superinfections.
- This led to endocarditis affecting a structurally normal aortic valve.
Findings:
- The patient presented with a harsh diastolic murmur, leading to diagnosis of aortic valve endocarditis.
- Initial treatment with intravenous penicillin G was followed by worsening symptoms and echocardiographic evidence of a large vegetation.
- The patient developed congestive heart failure, requiring further treatment and eventual aortic valve replacement via the Ross procedure.
Implications:
- This case represents the first reported instance of GABHS bacteremia and endocarditis following varicella in a previously vaccinated, immunocompetent child with a normal heart.
- Healthcare providers must consider serious complications like bacteremia and endocarditis in varicella patients, even without obvious skin infections.
- Vaccination against varicella does not eliminate infection risk entirely, and parents should be aware of potential, albeit rare, severe outcomes.
Abstract:
Varicella is generally a benign, self-limited childhood illness; however, severe, life-threatening complications do occur. A live, attenuated vaccine exists to prevent this illness, but controversy remains concerning the need to vaccinate children for what is generally a benign, self-limited disease, although more states are currently recommending this vaccine. We report a previously healthy 3-year-old who developed varicella 6 months after vaccination with no apparent skin superinfections, who subsequently developed group A beta-hemolytic streptococcus (GABHS) bacteremia resulting in endocarditis of a normal heart valve. We are unaware of previous reports of endocarditis related to GABHS after varicella. After developing a harsh, diastolic murmur that led to an echocardiogram, aortic valve endocarditis was diagnosed. A 6-week course of intravenous penicillin G was administered. Two weeks after the initiation of therapy, the diastolic murmur was harsher, and echocardiography revealed a large vegetation on the posterior leaflet of the aortic valve, with severe aortic insufficiency and a dilated left ventricle. The patient subsequently developed congestive heart failure requiring readmission and aggressive management. One month after the initial echocardiogram, a repeat examination revealed worsening aortic regurgitation and mitral regurgitation. The patient received an additional 4 weeks of intravenous penicillin and gentamicin followed by aortic valve replacement using the Ross procedure. Our patient, the first reported case of bacteremia and endocarditis from GABHS after varicella, illustrates the need for the health care practitioner to consider both common and life-threatening complications in patients with varicella. While cellulitis, encephalitis, and septic arthritis may be readily apparent on physical examination and commonly recognized complications of varicella, the possibility of bacteremia without an obvious skin superinfection should also be entertained. The case we report is unique in that the patient had normal immune function, had been previously vaccinated, and developed a rare complication of varicella-endocarditis-in a structurally normal heart with a previously unreported pathogen. Although a child may have been vaccinated against varicella, the chance of contracting the virus still exists and parents should be informed of this risk. group A beta-hemolytic streptococcus, endocarditis, varicella, Varivax, complications of varicella.