Endocarditis Attributable to Group A b-Hemolytic Streptococcus After Uncomplicated Varicella in a Vaccinated Child

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 b-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. Pediatrics 2000;106(3). URL: http://www.pediatrics.org/ cgi/content/full/106/3/e40; group A b-hemolytic streptococcus, endocarditis, varicella, Varivax, complications of varicella. ABBREVIATION. GABHS, group A b-hemolytic streptococcus. The clinical spectrum of varicella ranges from a benign, self-limited disease to potentially lifethreatening complications from both varicella and bacterial superinfections, such as cellulitis, pneumonitis, necrotizing fasciitis, encephalitis, epiglottitis, myocarditis, and endocarditis. Superinfection of varicella skin lesions with group A b-hemolytic streptococcus (GABHS) is the most common complication of primary varicella infection. This focus of infection may serve as a portal of infection for bacteremia and more serious complications. We report a child who developed varicella 6 months after vaccination with no apparent skin superinfections, who subsequently developed GABHS bacteremia resulting in endocarditis of a normal heart valve.