Endocarditis attributable to group A beta-hemolytic streptococcus after uncomplicated varicella in a vaccinated child

Varicella is generally a benign, self-limited childhood illness; however, s evere, 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 vacci nation with no apparent skin superinfections, who subsequently developed gr oup A beta-hemolytic streptococcus (GABHS) bacteremia resulting in endocard itis of a normal heart valve. We are unaware of previous reports of endocar ditis related to GABHS after varicella. After developing a harsh, diastolic murmur that led to an echocardiogram, a ortic valve endocarditis was diagnosed. A 6-week course of intravenous peni cillin G was administered. Two weeks after the initiation of therapy, the d iastolic murmur was harsher, and echocardiography revealed a large vegetati on on the posterior leaflet of the aortic valve, with severe aortic insuffi ciency and a dilated left ventricle. The patient subsequently developed con gestive heart failure requiring readmission and aggressive management. One month after the initial echocardiogram, a repeat examination revealed worse ning aortic regurgitation and mitral regurgitation. The patient received an additional 4 weeks of intravenous penicillin and gentamicin followed by ao rtic valve replacement using the Ross procedure. Our patient, the first reported case of bacteremia and endocarditis from GA BHS 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 rea dily apparent on physical examination and commonly recognized complications of varicella, the possibility of bacteremia without an obvious skin superi nfection should also be entertained. The case we report is unique in that t he patient had normal immune function, had been previously vaccinated, and developed a rare complication of varicella-endocarditis-in a structurally n ormal heart with a previously unreported pathogen. Although a child may hav e been vaccinated against varicella, the chance of contracting the virus st ill exists and parents should be informed of this risk.