Age: 79.0
Sex: M
Vaccine: FLUX
Symptoms: Fall, Nuclear magnetic resonance imaging brain abnormal, Rhinorrhoea, Ultrasound Doppler normal
Clinical narrative: This medically confirmed report (initial receipt 31-Dec-2014) concerns a 79 year old male patient, who had a medical history of stroke in 2009. The subject had a recent history of atrial fibrillation (see 2014045133). At the time of the event the subject concomitantly suffered from hypertension since 2009, acid reflux since 2012, erectile dysfunction since 2007, depression since 2004, benign prostate hyperplasia since 2008 and osteoarthritis in the left knee since 2000. Concomitant medications included oral silodosin (8mg daily) since 27-Aug-2014 for benign prostatic hyperplasia, oral clopidogrel (75mg daily) since 2009 for stroke which was ceased on 10-Sep-2014, oral tramadol (50mg as needed) since 2010 for osteoarthritis of the left knee, oral celecoxib (200mg twice daily) since 2012 for osteoarthritis of the left knee which was ceased on 10-Sep-2014, oral finasteride (5mg daily) since 2009 for benign prostatic hyperplasia, oral lisinopril (20mg twice daily) since 2008 for hypertension, oral hydrochlorothiazide (25mg daily) since 2008 for hypertension which was ceased on 12-Sep-2014, oral alprazolam (0.5mg as needed) since 2004 for depression, oral lansoprazole (30mg daily) since 2012 for acid reflux, oral tadalafil (20mg daily) since 2007 for erectile dysfunction, oral diltiazem (240mg daily) since 2010 for hypertension which was ceased on 11-Sep-2014 and re-commenced on 360mg daily on 12-Sep-2014, oral amiodarone (200mg twice daily) for the treatment of atrial fibrillation (see 2014045133) and a cortisone injection (one injection in both knees) via the intra-articular route once for osteoarthritis of the right and left knee. The patient had last received the influenza vaccine in Oct-2013. On the 29-Aug-2014 at 16:30, the patient received an influenza vaccine (trivalent or quadrivalent) in the left deltoid via the intramuscular route as part of clinical trial. On the 30-Aug-2014, the subject commenced oral loratadine (20mg twice daily) and was ceased on 01-Sep-2014 for the treatment of a runny nose. On the 25-Sep-2014, the patient received seasonal flu vaccine (manufacturer and batch number not specified) 0.5mL via the intramuscular route. On the 06-Oct-2014, the subject received oral celecoxib (200mg twice daily) for osteoarthritis of the right and left knee. On the 09-Oct-2014, the subject commenced oral clopidogrel (75mg daily) for the treatment of the past medical history of stroke. On the 14-Dec-2014, the subject developed a severe stroke. Medical advice was sought and concomitant medications were taken. On the 14-Dec-2014, the subject was admitted to hospital for an evaluation of a three week history of dizziness and falls. An MRI (Magnetic Resonance Imaging) and CT (Computed Tomogram) scan of the brain showed a chronic infarct of the cerebellum without acute change. The MRI also showed non-specific white matter changes that were felt to be chronic and microvascular in nature. Carotid ultrasounds showed no significant lesions. On the 17-Dec-2014, the subject was discharged from hospital. Outcome was recovering. Case linked to 2014045133, 2014045164 and 2015047684.