Age: 58.0
Sex: F
Vaccine: VARZOS
Symptoms: Injection site swelling, Liver function test normal, Metabolic function test normal, Nuclear magnetic resonance imaging, Pain
Clinical narrative: Information has been received from a health professional concerning a 58 year old 164 lb. white female with osteoporosis, osteoarthritis, iron deficiency anemia, pelvic discomfort and recurrent shingles and a history of papilloma viral infection, dysplasia, normal cervical Pap smear, deep vein thrombosis with pulmonary embolism (at age 23 related to the use of birth control pills), adenotonsillectomy, tubal ligation, occasional alcohol use and rhinitis allergic who on 14-AUG-2007 received a .75 cc subcutaneous dose in the left arm of Zostavax (Oka/Merck).  Concomitant therapy included alendronate sodium (MSD), fluticasone propionate (Flonase), fexofenadine hydrochloride (Allegra), calcium (unspecified), vitamin D (unspecified) and acyclovir (as needed).  On 14-AUG-2007 the patient experienced discomfort and swelling in her left arm at the injection site.  The patient was taking acetaminophen (Tylenol Arthritis) with no relief.  The patient subsequently took ibuprofen (Advil) and the pain had decreased.  The pain was from her deltoid to elbow area.  Additional information has been received from a medical records concerning a 58 year old white female.  On 14-AUG-2007, diagnostic base line studies revealed an EKG of normal sinus rhythm at a rate of 74 beats per minute, a blood pressure of 138/90, and CBC, BMP, liver function tests, TSH, cholesterol panel and UA all within normal limits.  On 14-AUG-2007, she received Zostavax (Oka/Merck) (MSD) as part of the physician's treatment plan for management of recurrent shingles.  On 18-SEP-2007, she was seen in the physician's office by a nurse practitioner who reported that since the vaccination injection (14-SEP-2007) the patient had developed left arm soreness for a few days but since then has had an ache that radiated from her upper left arm down to almost her elbow.  The patient had self-medicated herself with acetaminophen (Tylenol Arthritis) without much help.  On 16-SEP-2007 and 17-SEP-2007, the patient self medicated with two over the counter ibuprofen which significantly reduced the pain.  Upon physical examination there was reported a trace amount of swelling over her left deltoid compared to her right.  Diagnostics included CK (normal), and sedimentation rate (23).  The assessment and treatment plan was left arm pain, possible adverse drug reaction to Zostavax (Oka/Merck) (MSD).  Recommended therapy included the implementation of a three day course of ibuprofen 600 mg around the clock for 3 days, and then as needed.  On 26-SEP-2007, she underwent a follow up examination for ongoing pain in the left deltoid and bicep/tricep area.  The patient reported to the physician that she thought the nurse went a little too high and too deep with the injection.  On examination the physician reported that the upper left arm looked grossly normal, no warmth, swelling or erythema and was slightly tender in the general soft tissue region.  The physician's assessment and plan was left upper arm/deltoid pain.  The physician reported that he was concerned that the injection may not have been subcutaneous but, in fact it may have been deeper into the muscle raising the concern of possible foreign body type reaction in the muscle or other process.  The physician's recommendations included an MRI scan of her deltoid and humerus (results not reported) and to alternate ibuprofen and acetaminophen.