Age: 31.0
Sex: F
Vaccine: SMALL, YF
Symptoms: Musculoskeletal stiffness, Myalgia, Nausea, Protein urine present, Pyrexia
Clinical narrative: Initial case was retrieved from the scientific literature on 31 May 2010. A 31-year-old female patient, with a medical history of metrorrhagia, received an injection (route and site not provided) of Yellow Fever 17D, (Lot 1873GK) and an injection (route and site not provided) of Smallpox Vaccine in anticipation of travel. "Three days after vaccination, she had sudden onset of fever to 103 degrees Fahrenheit, myalgia, headache, chills, constipation, nausea, and vomiting, and also had swelling, pain, and stiffness at the site of her yellow fever (but not the smallpox) vaccination. On admission to the hospital, she was acutely ill, with temperature of 105 deg F, blood pressure 110/60, pulse 84, and respiration's 20. Her physical exam was unremarkable. The white blood count (WBC) was 8400 cells/mm3 with a striking left shift (91% polymorphonuclear cells, 5% bands, 2% lymphocytes, 2% monocytes) raising the suspicion of bacterial infection. She was anemic (hematocrit 28.4%). Electrolytes were normal, blood urea nitrogen (BUN) was slightly elevated but creatinine was normal (.9 mg/dL). There was 1-2 + protein in urine, mildly elevated amylase, and the asparate aminotransferase (SGOT) was elevated (107 U/L). Her anemia was believed caused by a long history of metrorrhagia. Over the next 7 days in the hospital, the patient continued to run a high fever and required a hypothermia blanket to maintain her temperature between 100 and 102 deg F. She was treated with intravenous hydration and antiemetics. She experienced shaking chills, severe headache, abdominal pain, nausea, and muscle aches, and at times was obtunded. Her liver became palpable and was tender. She was unable to eat until the sixth hospital day. Her liver enzymes rose to a peak SGOT of approximately 800 U/L, SGPT 542 U/L, and LDH 775 U/L. Coagulation tests were normal. She did not become jaundiced, and her maximum total bilirubin was 1.6 mg/dL. Liver scan showed inhomogeneous uptake but was considered "probably normal"; spleen scan and abdominal ultrasound were unremarkable; blood cultures febrile agglutinins, and mono spot test were negative. Blood obtained 6 days after onset was cultured for virus and found negative. A liver biopsy was performed on the fifth hospital day (10 days after vaccination), and was abnormal, showing significant diffuse microvesicular steatosis, liver cell drop-out, Kupffer cell prominence, scattered Councilman bodies, increased intracellular bile staining, without inflammation or midzonal distribution. The liver was sent and immunofluorescent staining performed with yellow fever antibody; results were negative. The patient improved during the second week after admission, liver enzymes normalized and symptoms dissipated. She was discharged 14 days after admission, with a diagnosis of "Viremia non-defined following yellow fever immunization, with hepatocellular inflammation, prolonged high fever. During the course of her hospitalization, consultations were held with hospital specialists (gastroenterology infectious disease) and with outside experts". Documents held by sender: None.