Al. Laskey et al., Endocarditis attributable to group A beta-hemolytic streptococcus after uncomplicated varicella in a vaccinated child, PEDIATRICS, 106(3), 2000, pp. NIL_65-NIL_66
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.