On 13 July 2002, a 62-year-old man was sent to the emergency room due to paraparesis after he received Chinese traditional chiropractic treatment from a nonprofessional. He was diagnosed with spondylitis with a T8 compression fracture and T9 myelopathy, suspected tuberculosis (TB) of the spine, and paraparesis and was transferred to a neurologic (internal medicine) ward in the evening. The next day he underwent surgery for total laminectomy (from T8 to T9) and hook system (from T6 to T11), and was sent to the surgical intensive care unit (SICU) for 5 days. On 18 July 2002, the patient was transferred to the neurologic surgery ward where the nurse worked.
Because the patient was suspected of having TB of the spine, he underwent pleural and video-assisted thoracoscopic surgery (VATS) biopsy on 1 August. According to the nurse's observation, the patient was worried, anxious, and under a great deal of stress regarding his health because his income was the primary financial resource of his family. On 3 August, multiple pruritic rash and vesicles were found over the patient's abdomen and lower back flank area. Herpes zoster was confirmed by a dermatologic physician.
During the patient's hospitalization in the neurologic surgery ward, the nurse attended the patient for several days (on 19-22 July, 29 July, 31 July-1 August, and 4-5 August 2002) before she resigned from the job on 12 August. Her regular nursing care tasks included measuring body temperature, blood pressure, and pulse; administering medicine; asking how the patient was feeling; and helping the patient to change his bed rest position.
At the age of 5 years, the nurse had been infected with chickenpox by her kindergarten-age sister, who herself was previously infected by her kindergarten classmates. At that time, the nurse, her sister, and her brother had multiple chickenpox vesicles on their faces simultaneously. Because of her previous chickenpox history, it was supposed that the nurse was immune to the VZV; while caring for the patient, she did not wear gloves, a mask, or an isolation gown before the herpes zoster was confirmed.
Because she had passed the admission examination for graduate study in a medical school, the nurse planned to resign her job to become a full-time student by 15 August. Before she resigned, she took a short vacation to her hometown in Ping-Tung County, in the south of Taiwan, on 6 August. However, on 8 August, she developed a high fever (39.5 C, 103.1 F), malaise, and headache. She went to a private clinic and was diagnosed with influenza by a physician in her hometown. The next day, in addition to the prodromal symptoms, pruritic rash started to appear on her face, neck, and trunk. She came back to the teaching general hospital in Taipei on 9 August and was diagnosed with varicella without mention of complication (ICD-9 code 052.9) by another dermatologic physician (not the herpes zoster patient's dermatologic physician). The nurse received treatment with Allegra (fexofenadine, 60 mg twice per day; Hoechst, Kansas City, MO, USA), chlorpheniramine (4 mg three time per day; Mine Ta Chemistry Pharmacy Co., Ltd., Tai Chung, Taiwan), and Scanol (acetominophen, 500 mg three times per day; Scanpharm, Birkerod, Denmark) for 14 days. Because her clinical symptoms were very clear, no laboratory confirmation testing was performed at that time. However, to confirm this second varicella episode before reporting this case, we invited the nurse to take serologic tests for varicella antibody on 4 April 2005. The results indicated that VZV-specific IgM was negative [< 1:20; Merifluor VZV IgM indirect fluorescent antibody, (IFA); Meridian Bioscience Inc., Cincinnati, OH, USA], but the VZV IgG was positive (1:80 on the basis of > 1:10, Merifluor VZV IgG IFA), with high sensitivity (93.9% for IgM and 100% for IgG) and high specificity (100% for both antibodies) according to the manufacturer's instructions.
Negative specific serum IgM and positive specific serum IgG indicated a past VZV infection. Because varicella and herpes zoster both resulted from the same antigen, the VZV IgG-positive reaction was excluded from the herpes zoster. It was also excluded because the nurse did not get herpes zoster from the second episode of varicella on 9 August 2002 to 4 April 2005. The nurse is now convalescing.