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Year : 2021  |  Volume : 13  |  Issue : 3  |  Page : 142-144
Varicella infection in an immunized pediatric living donor liver-transplant recipient

1 Department of Clinical Virology, Institute of Liver and Biliary Sciences, New Delhi, India
2 Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
3 Department of Transplant Surgery, Institute of Liver and Biliary Sciences, New Delhi, India

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Date of Submission24-Feb-2021
Date of Acceptance15-Apr-2021
Date of Web Publication19-Aug-2021


Varicella-zoster virus (VZV) is a DNA virus belonging to the Herpesviridae family. Primary infection causes chickenpox followed by latency in the sensory ganglia, which can sometimes reactivate leading to herpes zoster. Chicken pox is generally a mild disease of childhood with a secondary attack rate of >85%, but disseminated VZV infection with visceral involvement and fatal outcome may occur in immunocompromised individuals. Indian Academy of Pediatrics recommends two doses of live-attenuated varicella vaccine in healthy unexposed children at 15–18 months and then at 4–6 years of age. The effectiveness of a single dose of vaccine is around 85% and with a two-dose schedule is as high as 92%. Despite the vaccine-induced protection, community-acquired VZV infections still remain a problem in immunocompromised population. We hereby report a case of a previously immunized pediatric liver-transplant recipient who acquired VZV infection. This case report clearly highlights the importance of strict environmental infection control practices, early suspicion, diagnosis, and management in such cases.

Keywords: Disseminated infection, DNA polymerase chain reaction, living donor liver transplantation, vaccine efficacy, varicella-zoster virus, varicella-zoster virus infection

How to cite this article:
Mehta V, Ramachandran K, Agarwal R, Alam S, Pamecha V, Gupta E. Varicella infection in an immunized pediatric living donor liver-transplant recipient. J Global Infect Dis 2021;13:142-4

How to cite this URL:
Mehta V, Ramachandran K, Agarwal R, Alam S, Pamecha V, Gupta E. Varicella infection in an immunized pediatric living donor liver-transplant recipient. J Global Infect Dis [serial online] 2021 [cited 2022 May 25];13:142-4. Available from:

   Introduction Top

Varicella-zoster virus (VZV) is a DNA virus of Herperviridae family, which causes both chicken pox as primary infection and herpes zoster as reactivation.[1] Chicken pox is mild disease of childhood but has greater morbidity in adolescent and adult population.[1] The overall seroprevalence in India was around 68.2% in 2000 with a seroprevalence rate of 29% in 1–5 years group to 71.2% at the age of 11–15 years and 91.1% at the age of 31–40 years.[2]

Although the primary infection is benign in immunocompetent population, disseminated VZV infection may occur in children <1 year of age, immunocompromised individuals, and those with impaired cell-mediated immunity.[3]

Varicella vaccination is an effective preventive tool (efficacy of >85%) [Table 1] for decreasing the burden and complications of varicella disease although it is less efficacious than natural VZV infection.[4] Primary infection in such individuals often results in suspension or delay of surgery/chemotherapy, thus increasing the risk of progression of underlying disease.[3]
Table 1: Seroconversion and efficacy of one and two doses of live-attenuated varicella vaccine (Oka stain)[3],[4],[5]

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We hereby report a case of an immunized pediatric liver donor liver-transplant recipient who acquired VZV infection.

   Case Report Top

A 6-year-old male child, 10 months prior, underwent an emergency live donor liver transplantation for acute liver failure secondary to hepatitis A infection. He now presented to the emergency with chief complaints of poor oral intake, high-grade fever with chills, and rigors (102°F) for 3 days and vesicular rashes of 2–3 days [Figure 1]. Vesicular rash was first noticed by the parents on the chest and shoulders which progressed onto the trunk, abdomen, face, and lower limbs; palms and soles were spared. The patient was on posttransplant immunosuppressive regimen with tacrolimus, cyclosporine, and mycophenolate mofetil. At the time of presentation, recipients' graft function was normal and no associated systemic abnormality was detected. Donor for the patient had pretransplant seropositive (IgG-positive) status for VZV, Epstein–Barr virus (EBV), and Cytomegalovirus (CMV) and no current active infection. The recipient's pretransplant serological status was also positive for VZV, EBV, and CMV. The recipient never had any history of natural infection to VZV before transplant nor has been exposed to any individual with chicken pox or varicella-zoster immunoglobulin, but parents gave the history of receiving VZV vaccination two doses (at 2 and 4 years of age), last dose taken 2 years before transplant. Anti-VZV IgG protective titers could not be measured. At present, the clinical presentation was generalized and not limited to any particular dermatome. We could not investigate the strain type so were unable to determine whether his/her infection was primary infection or vaccine strain re-activation. Hence, a clinical diagnosis of posttransplant VZV infection was made, despite the seropositive status.
Figure 1: Vesicular skin lesions of the patient, at the time of presentation

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Blood samples were sent to the virology laboratory for further workup and confirmation of diagnosis. VZV IgM was positive and plasma VZV-DNA load was 4 log10 copies/mL by real-time polymerase chain reaction (PCR) assay. The patient received symptomatic treatment along with intravenous acyclovir (20 mg/kg/dose IV tds) and IV antibiotics (augmentin 20 mg/kg/day IV tds) for a 7-day period. All the immunosuppressant medications were briefly withheld. The patient clinically improved and the follow-up blood specimen was negative for VZV DNA after 7 days. The patient was eventually discharged, and written informed consent was obtained from the parents for the case report to be published.

   Discussion Top

Chicken pox is a self-limiting disease in healthy pediatric population, yet it carries the risk of dissemination in immunocompromised.[1]

VZV disease is a frequent community-acquired (>6 months) infectious complication of solid organ-transplant (SOT) recipients. With high doses of immunosuppressants, fatal complications such as disseminated infections with visceral involvement are reported.[5] However, varicella after transplantation is mild when patients are suspected and investigated early, hospitalized, and given immediate treatment.[6]

Primary infection is rare in adult SOT recipients (seronegativity of 2%–3%) but more in pediatric transplant recipients (seronegativity ranges from 7% to 50%).[6] Various factors such as age of the child, prior vaccination, history of varicella disease, and level of immunosuppression before transplant may influence the serostatus of the pediatric group.[7] Such cases are mainly community acquired, but still donor-derived varicella is reported but rare.[1]

Vaccination is an effective prevention tool against VZV infection. Indian Association of Pediatrics recommends two doses of live-attenuated (Oka strain) vaccine to be administered, first dose at the age of 15–18 months and the second dose at the age of 4–6 years.[4] The seroconversion rate and efficacy of the two doses of the vaccine are tabulated in [Table 1]. This vaccine is presently not given under the Universal Immunisation Programme in India, thus leading to decreased herd immunity and frequent outbreaks in immunocompromised patients.[4] In SOT recipients, Infectious Diseases Society of America guidelines recommend completing pretransplant vaccination with live-attenuated vaccine in patients who are seronegative for VZV, >4 weeks before initiation of any immunosuppression.[5]

Despite the vaccine efficacy, breakthrough varicella can still occur.[1] This has a milder presentation among immunocompetent individuals; disseminated infection has been reported in immunocompromised, especially in those who did not develop immunity following vaccine or in whom the pretransplant-induced immunity waned off as a result of immunosuppression[6] The present case is a case of breakthrough VZV infection in a vaccinated child post transplantation. This raises the question of exploration into the need of a third-dose VZV vaccine and justified routine evaluation for seroconversion after two doses. Studies in pediatric transplant recipients suggest that varicella vaccine is safe and immunogenic even after transplantation but must be performed only in selected patients with appropriate education and close follow-up.[7]

Our literature search revealed few similar case reports of VZV infection in both immunocompetent and immunocompromised population reported from India [Table 2].
Table 2: Breakthrough varicella cases reported from India in both immunocompetent and compromised patients

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The present case highlights the importance of counseling the patients on environmentally acquired diseases and infection control practices. PCR-based early diagnosis and intensive treatment and effective monitoring may prevent disease and its dissemination.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Research quality and ethics statement

The authors followed applicable EQUATOR Network (“ guidelines, notably the CARE guideline, during the conduct of this report.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Kliegman R, Stanton B, St Geme J, Schor N, Behrman R, Nelson W. Nelson Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier; 2016. p. 1580-2.  Back to cited text no. 1
Lokeshwar MR, Agrawal A, Subbarao SD, Chakraborty MS, Ram Prasad AV, Weil J, et al. Age related seroprevalence of antibodies to varicella in India. Indian Pediatr 2000;37:714-9.  Back to cited text no. 2
Sartori AM. A review of the varicella vaccine in immunocompromised individuals. Int J Infect Dis 2004;8:259-70.  Back to cited text no. 3
Vashishtha VM, Choudhury P, Kalra A, Bose A, Thacker N, Yewala VN, et al. Indian Academy of Pediatrics (IAP) recommended immunization schedule for children aged 0 through 18 years – India, 2014 and updates on immunization. Indian Pediatr 2014;51:785-800.  Back to cited text no. 4
Rubin LG, Levin MJ, Ljungman P, Davies EG, Avery R, Tomblyn M, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. ClinInfect Dis. 2014;58:e44-100.  Back to cited text no. 5
Posfay-Barbe KM, Pittet LF, Sottas C, Grillet S, Wildhaber BE, Rodriguez M, et al. Varicella-zoster immunization in pediatric liver transplant recipients: Safe and immunogenic. Am J Transplant 2012;12:2974-85.  Back to cited text no. 6
Pergam SA, Limaye AP. On behalf of the AST Infectious Diseases Community of Practice. Varicella zoster virus in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019;33:e13622.  Back to cited text no. 7
Suryam V, Das AL. Chickenpox appearing in previously vaccinated individuals. Med J Armed Forces India 2009;65:280-1.  Back to cited text no. 8
Dubey M, Singh G, Bhatti VK, Mahen A, Kunte R, Katara SK. Reinfection of Varicella zoster in a vaccinated adult. Med J Armed Forces India 2015;71:S214-6.  Back to cited text no. 9
Guru V, Radhakrishnan V, Sagar T. Varicella vaccination in children with acute lymphoblastic leukemia: Experience from a pediatric cancer centre in India. Pediatric Hematol Oncol J 2019;4:31-4.  Back to cited text no. 10

Correspondence Address:
Dr. Ekta Gupta
Department of Clinical Virology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jgid.jgid_233_20

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  [Table 1], [Table 2]


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