Age: 49.0
Sex: F
Vaccine: FLU4
Symptoms: Nitrite urine absent, Pain, Petechiae, Pruritus, Pyelonephritis
Clinical narrative: Patient received seasonal flu vaccine on 10-10-2016. On 10-18-2016, she presented back to the clinic with complaints of chest pain, fever, chills, fatigue, generalized weakness and syncope. VS: BP: 102/77, HR: 103, T: 101.8, SAO2: 93%. She was brought to the office by her daughter. Onset had been 3 days prior. She was alert and oriented, but did show some signs of confusion. Her ECG showed t-wave changes and she tested positive in office with Influenza Type B. She was sent to a local Emergency Department. Work-up in the ED consisted of chest X-ray which was normal. CT abd/pelvis demonstrated nothing acute, Doppler ultrasound of the legs ruled out DVT. ECG there was consistent with one done in clinic, but felt to be her normal baseline from comparison of previous ECG. Labs: CMP essentially normal, CBC mild anemia, Lipase normal, Troponin normal, UA showed small leuks, trace blood, negative bacteria and nitrates. Her ED working diagnoses were Abdominal pain, Pyelonephritis, Vomiting, Chronic Narcotic Dependence, Sciatica and Constipation. She was discharged home with ondansetron and promethazine for vomiting. She was seen a few times in office for persistent cough and unrelated issues toward the end of 2016. On 1-18-2017, she presented with multiple complaints, one of which was new onset of ?random sores all over her body? that itch and were painful. A CBC was drawn which again showed mild anemia, but WBCs and diff were normal. On March 15, 2017, I performed a punch biopsy of one of the lesions on her left leg that was developing. The specimen was sent to lab. The microscopic description was: The dermis shows an inflammatory infiltrate of lymphocytes and eosinophils. The pathologist felt consistent with arthropod bite reaction. She was treated for such, but her skin lesions continued to increased in number and frequency. A couple of weeks later, I got her in to see a local dermatologist who performed another biopsy, this time from a lesion on her arm. His diagnosis was Prurigo Nodularis. Although this condition can be seen in persons with kidney disease, her lesions have never appeared to be nodular and at this point, I have examined well over 100 lesions on her. I have in fact had her wait in office when a new lesion presents as a tiny reddened petechial type lesion that progresses over nearly an hour to form flat vascular erythematous lesions, then into a bulla and erupt causing severe pain.  On several occasions she has had multiple lesions erupting at once, causing her clothing to stick to her skin and I have had to cover large areas with creams and non-stick bandages. For nearly a year the lesions occurred to her entire body surface area, but spared her face and right leg. Over the past several months the lesions are now affecting those areas too. I have cycles her off of each of her past and current medications in an attempt to isolate an extraneous cause. None of the changes have affected the progresive nature of the disease, which now seems to be an idiopathic form of erythema multiforme. The lesions have severely scarred her skin causing irregular hypopigmentation and the chronic inflammation seems to have caused widespread Chronic Regional Pain Syndrome. I have also attempted to get her seen at Clinic and after much correspondence they have declined to see her.  She has also seen another local dermatologist who has taken an interest in her case, but unfortunately his treatment plan has not proven beneficial. I have also tried her on immune system modifying agents such as methotrexate. This seemed to slow the frequency for about 1 month and then return to her current status of daily skin eruptions.