Post-Varicella Vaccination Uveitis in a Child with Nephrotic Syndrome receiving Immunosuppressive Treatment: A Case Report

Catarina Jardim Andrade ^1,2 Miguel Cordeiro ³ Rute Baptista ^4,5,6 Beatriz Sousa Nunes ^6,7 Ana Margarida Garcia ^1,6 Tiago Milheiro Silva ^1,6 Marta Valente Pinto ^6,8,9*

• ¹ Infectious Diseases Unit, Unidade Local de Saúde São José, Hospital de Dona Estefânia, Lisbon, Portugal
• ² Pediatrics, Hospital Central do Funchal, SESARAM, EPERAM, Funchal, Portugal
• ³ Ophthalmology Department, Unidade Local de Saúde de Lisboa Ocidental, Lisbon, Portugal
• ⁴ Paediatric Nephrology Unit, Unidade Local de Saúde São José, Hospital de Dona Estefânia, Lisbon, Portugal
• ⁵ Faculty of Medicine, NOVA University of Lisbon, Lisbon, Lisboa, Portugal
• ⁶ Centro Clínico Académico de Lisboa, Lisboa, Portugal
• ⁷ Infectious Diseases Unit, Hospital de Dona Estefânia, Lisbon, Portugal
• ⁸ Primary Immunodeficiency Unit, Unidade Local de Saúde São José, Hospital de Dona Estefânia, Lisbon, Portugal
• ⁹ Egas Moniz Center for Interdisciplinary Research (CiiEM), Almada, Setúbal, Portugal

Patients with nephrotic syndrome are at heightened risk of infections due to the underlying disease pathophysiology and the effects of immunosuppressive therapies. Varicella-zoster virus (VZV) infection can cause severe complications in immunocompromised individuals. Concerns about the safety of live attenuated vaccines in this population persist. Emerging vaccination strategies incorporate pre-vaccination risk stratification algorithms based on immunological criteria. We present a case of a five-year-old male with corticosteroid-dependent nephrotic syndrome, in complete remission on mycophenolate mofetil therapy, who received the varicella vaccine after meeting immunocompetence criteria. Fourteen days post-vaccination, he developed scant vesicular lesions, with VZV DNA detected by PCR via swab. By day 16 post-vaccination, he presented with left-eye panuveitis. VZV DNA was also detected in the blood by PCR. Differentiation of VZV vaccine strains from wild-type strains was not possible. Additionally, molecular testing for VZV in the aqueous humor was not performed. However, given the temporal association with varicella vaccination, the detection of VZV in the blood and cutaneous lesions, and most importantly, the immunosuppression of the patient, post-vaccination ocular varicella was assumed even without an epidemiological history of varicella exposure. This case highlights the importance of a thorough immunocompetence assessment before administering live vaccines to immunosuppressed patients, as well as close post-vaccine monitoring and a high index of suspicion for complications to optimize vaccine safety in this vulnerable group. Patients with nephrotic syndrome require vaccination strategies tailored to their individual risk.