Sex: M
Vaccine: MNQ
Symptoms: Lymphocyte percentage decreased, Meningitis, Monocyte percentage increased, Murine typhus, Neck pain
Clinical narrative: Rickettsia meningitis; Rickettsia; Fever; Headache; Rash/worsening of rash (spreading from his hands and arms to his trunk and legs); Joint pain; Irritability; Photophobic; Agitated; Distress; Crying; Pain; flexion of neck; Tachycardia; Tachypneic; ankle swollen; Ankle decreased range of motion; Pain ankle; petechial rash; Hyponatremia; This case was reported in a literature article and described the occurrence of meningitis in a 12-year-old male patient who received Men ACWY-CRM NVS (Meningococcal ACWY Vaccine (potential Menveo)) for prophylaxis.   Previously administered products included immunization (immunizations were up to date).   On an unknown date, the patient received Meningococcal ACWY Vaccine (potential Menveo) at an unknown dose. On an unknown date, unknown after receiving Meningococcal ACWY Vaccine (potential Menveo), the patient experienced fever, headache, rash, joint pain and irritability. The patient was treated with amoxicillin + clavulanic acid (Amoxicillin + Clavulanate). On an unknown date, the outcome of the fever, headache, rash, joint pain and irritability were unknown.   The reporter considered the fever, headache, rash, joint pain and irritability to be related to Meningococcal ACWY Vaccine (potential Menveo).  Additional details were provided as follows: This case was reported in a literature article and described the occurrence of fever and headache in a 12-year-old male patient who was vaccinated with unspecified quadrivalent meningococcal vaccine (manufacturer unknown) for prophylaxis.  The patient was previously healthy and his immunizations were up to date. The patient and his family resided in a single-family. No information on patient's concurrent condition or concomitant medication was provided. On an unspecified date, the patient received 1st dose of unspecified quadrivalent meningococcal vaccine (administration route and site unspecified, batch number not provided). The age at vaccination was not provided.  On an unspecified date, an unknown period after vaccination, the patient presented with a 5-day history of fever to 103 deg. F and rash. The patient had also reported headache. On the first day of illness, the patient was evaluated by his pediatrician who recommended a 10-day course of amoxicillin/clavulanate. Five days into therapy, the patient continued to have fever, worsening of rash (spreading from his hands and arms to his trunk and legs), and new onset joint pain and irritability. The patient's pediatrician recommended inpatient evaluation. The outcome of the event was not reported. The authors did not comment on relation between the events and unspecified quadrivalent meningococcal vaccine. However, the authors stated, "Fever and headache in a fully vaccinated adolescent". This article is not available for regulatory submission due to copyright restriction.   Follow up information received from the physician on 15th October 2019: The family had a dog and a cat, both of which spent time outside where they were exposed to raccoons and opossums. The patient reported occasional ingestion of pasteurized imported cheeses. Three weeks before the onset of symptoms, he had gone camping where he was exposed to numerous insects. On an unspecified date, 3 weeks after the onset of the symptoms, the patient had an examination, he was febrile (101.5 degree F), photophobic, and agitated. The patient was in distress, crying, and asking for the examination lights to be turned off. He had pain with flexion of his neck and negative Kernig's/Brudzinski's signs. The patient was tachycardic with no murmurs and tachypneic with no adventitious sounds in the lung fields. His left ankle was swollen with decreased range of motion secondary to pain. A fine, nonblanching, petechial rash was noted on his trunk, notably on the hands and elbow (extremities)and throughout the patient's body. The patient had defervesced within 2 days of initiation of antimicrobials. Laboratory evaluation was notable for a complete blood count with 12 600 white blood cells/mm3 (63 percent segmented neutrophils, 25 percent bands, 3 percent lymphocytes, 9 percent monocytes), hemoglobin 12.3 g/dL, and platelets 167 000 platelets/µL. Blood chemistries revealed hyponatremia (serum sodium 126 mEq/L), and liver function tests showed mild transaminitis (aspartate aminotransferase and alanine aminotransferase of 41 and 61 U/L, respectively). Cerebrospinal fluid (CSF) analysis revealed 239 white blood cells/mm3 with (74 percent neutrophils) 2 red blood cells/mm3, protein 47 mg/dL, and glucose 55 mg/dL. His clinical presentation and laboratory evaluation were consistent with meningitis. Blood and CSF cultures were obtained and additional tests for influenza (nasal wash), human metapneumovirus (nasal wash), adenovirus (nasal wash), enterovirus (CSF polymerase chain reaction), Epstein-Barr virus (serology), arboviridae (serology), and tick/flea-borne (serology) etiologie were performed. The patient was admitted to the inpatient pediatric service where he was initially treated with vancomycin and ceftriaxone pending Cerebrospinal fluid (CSF) bacterial cultures. Doxycycline was initiated given the concern for Rickettsia typhi infection given his recent travel to an area of high endemicity. The patient had defervesced 36 hours after admission and he continued ceftriaxone and doxycycline for 5 and 10 days, respectively (i.e at day 1, the temperature was about 101.7 deg. F, at day 2, it was around 101.1 deg. F deg. F, at day 3, around 101.5 deg. F, at day 4, it was around, 99.9 deg. F, day 5, it was around 99.2 deg. F and day 6, it was around 98.8 deg. F). Bacterial cultures and viral studies from admission were negative; vancomycin was discontinued after CSF cultures showed no growth at 48 hours. Because he was pretreated with amoxicillin/clavulanate before his evaluation, he received ceftriaxone for 5-days for empiric meningococcal meningitis treatment, although this diagnosis was thought to be unlikely given the patient's duration of illness at the time of admission. Despite negative R typhi and Rickettsia rickettsia serologies, his rapid improvement on doxycycline was clinically consistent with rickettsial infection, so he was discharged home to complete a 10-day course of therapy.  This case has been considered serious due to hospitalization. The patient returned to clinic 1 month after his initial presentation; at that time, he had returned to school and was well with no recrudescence of fever or other symptomatology. Repeat R typhi serology was negative, as was testing for Coxiella burnetti. The authors commented, "Other than R rickettsii, Rickettsia species as a cause of meningitis in children is rare; however, it has been reported in children with consistent clinical exposure history." The author concluded, "When a rickettsial illness is suspected, it is important to collect both acute and convalescent serum, because seroconversion can be missed if testing is performed too early in the time course of infection. Furthermore, when a patient's exposure and clinical history are consistent with a rickettsial infection, empiric treatment is warranted before laboratory confirmation. Our patient had negative R typhi serologies on both acute and convalescent serum, suggesting perhaps an alternative diagnosis. His arthritis and rash could support a diagnosis of N meningitides meningitis; however, the arthritis associated with meningococcus is typically immune-mediated and presents days after and not with meningeal signs. His clinical presentation and rapid improvement on doxycycline are consistent with a rickettsial illness; however, infection due to other flea/tick-borne pathogens would have responded to this agent as well. The recent increase in R typhi infections guided our initial microbiologic evaluation; however, this focused approach did not include testing for Ehrlicia chaffeensis, which, although rare, is also consistent with his clinical presentation. Rickettsia prowazekii and Rickettsia felis are a consideration as well, and although there is a high-level of cross reactivity with serologic tests for R typhi, these etiologies may have been missed without specific testing."      Lab Comments: Lab test done on an unknown date. The patient clinical presentation and laboratory evaluation were consistent with meningitis.  Blood and CSF cultures were obtained and additional tests for influenza (nasal wash), human metapneumovirus (nasal wash), adenovirus (nasal wash), enterovirus (CSF polymerase chain reaction), Epstein-Barr virus (serology), arboviridae (serology), and tick/flea-borne (serology) etiologie were performed. Despite negative R typhi and Rickettsia rickettsia serologies, his rapid improvement on doxycycline was clinically consistent with rickettsial infection. Repeat R typhi serology was negative, as was testing for Coxiella burnetti.