Q:

5/30/2013
I have an 11 year old patient who has a history of reaction to the varicella vaccine 3 years ago. Following injection of his second dose, within 5 minutes he developed abdominal pain and a sensation of warmth, then an urticarial generalized rash, coughing, throat clearing, followed by vomiting and periorbital edema. He was treated with Epi, Benadryl, corticosteroids and improved.

He has been kept away from all vaccines since. He now required the meningococcal vaccine, and was referred to my office. Percutaneous testing was negative, but within 6 minutes of a 0.05 cc test dose, he developed a blotchy, highly pruritic rash at the site of injection, and blotchy erythematous lesions on his chest and back. With cetirizine he cleared within 30 minutes and he did not progress to other symptoms.

How can I determine what component of the vaccine could have caused this? Menactra does not appear to contain gelatin. His mother is worried about future vaccinations, and I am not sure what to advise? Thank you!

A:

Thank you for your inquiry, and for the information that the vaccines used were Menactra (meningococcal vaccine) and Varivax (Varicella vaccine).

Unfortunately I am not sure that I can be of any help. I have looked up the ingredients of both vaccines and there is nothing in common that could explain a reaction to both. I am not aware therefore of any procedure by which you might explain the reaction to each by invoking a common ingredient.

In addition, the issue is even more unusual because, although allergic reactions to Menactra have been reported, they are extremely rare.

Thus I am afraid I can offer you little help, and the only conclusion I can come to is that your patient has reacted, for unknown reasons to two separate ingredients, both of which are unknown, in each vaccine. However, because I am not able to pinpoint the substance responsible based on a review of the contents of each vaccine, I am asking Dr. John Kelso, who is the coauthor of the Joint Task Force Parameters on Reactions to Vaccines, if he can offer us any other explanation. As soon as we hear from Dr. Kelso, we will forward his response to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

We received a response from Dr. John Kelso. Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

Response from Dr. John Kelso:
According to Varicella vaccine (Varivax) contains sucrose, phosphate, glutamate, gelatin, monosodium L-glutamate, sodium phosphate dibasic, potassium phosphate monobasic, potassium chloride, sodium phosphate monobasic, EDTA, residual components of MRC-5 cells including DNA and protein, neomycin, fetal bovine serum, human diploid cell cultures and Meningococcal vaccine (MCV4Menactra) contains formaldehyde, phosphate buffers, Mueller Hinton agar, Watson Scherp media, Modified Mueller and Miller medium. Thus, I also do not see any common ingredients or have an explanation about some common thread in these 2 reactions.

Does the child have any known food allergies, including gelatin? I would be inclined to do a RAST to both bovine and porcine gelatins (they are extensively cross-reactive but I have occasionally had disparate results), and if negative a prick skin tests to gelatin (dissolve 1 teaspoon (5 g) of any sugared gelatin powder (for example Jell-O) in 5 mL of normal saline) to determine whether or not the child is allergic to gelatin as an explanation for the reaction to the varicella and subsequent vaccines he may need that would contain this ingredient (Influenza (Fluzone, Sanofi Pasteur), Influenza (FluMist, MedImmune Vaccines, Gaithersburg, Maryland), Measles, Mumps, Rubella (MMRII, Merck, Whitehouse Station, New Jersey), Measles, Mumps, Rubella, Varicella (ProQuad, Merck), Rabies (RabAvert, Novartis, Emeryville, California), Typhoid Vaccine Live Oral Ty21a (VIVOTIF, Berna, Coral Gables, Florida), Varicella (VARIVAX, Merck), Yellow Fever (YF-VAX, Sanofi Pasteur), Zoster (ZOSTAVAX, Merck).

Did the skin testing that was done to the Menactra include an intradermal test? If both a prick (full-strength) and ID skin tests (diluted 1:100) were negative, it is hard to imagine that the reaction was IgE mediated.

For subsequent vaccination, I would suggest having a discussion with the parents regarding the risk of vaccination versus the risk of remaining unvaccinated and consider vaccination in graded doses under observation (For a vaccine where the full dose is 0.5 mL, give the following doses at 15-minute intervals as tolerated: 0.05 mL 1:10 dilution, 0.05 mL full-strength, 0.1 mL full-strength, 0.15 mL full-strength, 0.2 mL full-strength) perhaps with pretreatment with antihistamines.

John Kelso

AAAAI - American Academy of Allergy Asthma & Immunology