Age: 70.0
Sex: M
Vaccine: HEP, YF, HEP, TYP, YF, HEP, YF
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Asthenia, Disseminated intravascular coagulation, Dyspnoea
Clinical narrative: From initial information received on 29/May/2003 from the Center of Disease Control and Prevention  (CDC) through telephone correspondence, it was reported that a 70 year old male patient received vaccinations for YV-VAX, Hepatitis B vaccine and Typhoid vaccine on 10/Apr/2003. The patient also received Hepatitis A vaccine on 02/Apr/2003. On 14/Apr/2003, the patient complained of "not feeling well" and on 16/Apr/2003, he called the vaccination clinic to report aching in his hips, back, neck and all over. Later his family doctor documented a temperature up to 103 degrees. The date of this doctor visit is unknown at this time. The patient was hospitalized on 17/Apr/2003 and expired the next day on 18/Apr/2003, at a community hospital. Laboratory results showed an AST greater than 6000, ALT greater than 200 and platelets 5200. Upon autopsy, a necrotic liver was revealed, as well a s a picture of DIC. No blood is available but fixed tissue has been sent to the CDC for follow-up testing. The patient history is positive for increased blood pressure, overweight, headaches and insomnia. No known immunodeficiency disease or steroid use. Concomitant medications are not known at this time. The CDC has requested autopsy results and medical records. From additional information received on 12/Jun/2003 from the CDC through e-mail correspondence. It was reported that the pathologist stated that the patient tested positive for yellow fever antigens. Multiple organs were positive for yellow fever on immunohistochemical examination, including the liver, lung, spleen, kidney, heart and pancreas. No other information was reported. From additional information received on 18/Jun/2003, it was reported that the patient was vaccinated with YF-VAX (lot number UB359AA) and Hepatitis B (Engerix-B, lot number ENG5305A6) on 10/Apr/2003; and medication included Proscar 5 mg daily, Toprol XL 200mg daily, Elavil 100 mg daily, Lescol 20 mg daily, Ultram 50 mg daily, and Norvasc 5 mg daily. The hospital admission record notes that the patient had been prescribed Sonata 5 mg as needed while traveling, Valium 10 mg as needed for travel anxiety, Diamox 500 mg as directed for mountain sickness while traveling, Cipro 500 mg for traveling and Malarone for malarial prophylaxis. It is not clear whether the patient had been taking these medications when he became ill. The hospital history and physical report was provided (a copy of which is on file) and indicated that the patient complained of weakness and shortness of breath and had not been feeling well for a few days. He was transported to the hospital by EMS with a blood pressures of 90/46 and a heart rate of 108. Within the emergency room, the patient was noted to be quite dry and had blood pressures as low as 60 systolic. He was also noted to be tachycardic. The patient was noted to have an abrasion involving the right pretibia. Blood and urine cultures were obtained, and the patient had a central line placed in his right femoral vein due to difficult access in the proximal venous circulation. While awaiting transfer to the critical care unit, he became increasingly more hypoxic and moribund. Intubation was immediately performed and a large mucous plug was extracted. The patient was maintained in the intubated state and transferred to the critical care unit. During the physical examination, his blood pressure was 102/59 with a pulse of 130 and regular, temperature of 100.4 F, respiratory rate of 27. The hospital admission assessment was as follows: Early sepsis with DIC possibly secondary to either a pulmonary, gastrointestinal or genitourinary source. The role of Malarone is unclear but probably not associated with an acutely decompensating state. Rule out ischemic bowel. DIC secondary to #1. Elevated liver chemistries probably related to #1. Passive congestion also an issue. Lactic acidosis related to #1. History of hypertension, benign, prostatic hypertrophy, hyperlipidemia and gastroesophageal reflux disease, all apparently stable. There has been a remote history of gastrointestinal bleed. Acute renal failure consistent with ATN. The patient was treated with Zosyn, Gentamicin, Zithromax, IV fluids and dopamine for blood pressure control. Pepcid prophylaxis was also given. Despite supportive therapy, the patient's overall condition deteriorated and he expired at 15:30 on 18/Apr/2003. An autopsy was performed on 19/Apr/2003 at 12:10. A copy of the autopsy report was provided and is on file. As per the autopsy report: Micro Exam- The significant findings in histology are as follows: Hyperacute and chronic ischemic heart disease which is evidenced by the presence of multiple foci of myocardium of the left ventricle showing waviness of myofibers with loss of cross striation and occasional contraction bands indicating hyperacute myocardial infraction. The coronary arteries show moderate to severe calcific atherosclerosis (main, LAD and RCA) with 40-100% luminal obliteration. Multiple foci of myocytes dropouts and interstitial fibrosis are also identified, indication remote ischemic events. Mild acute pericarditis. The sections of the heart also show mild neutrophile infiltrate in the pericardium consistent with a mild acute pericarditis. The sections of the liver show extensive hepatocyte necrosin with marked steatosis and minimal inflammation consistent with acute liver failure clinically. The sections of bilateral kidneys show arteriolosclerosis and glomerulosclerosis and interstitial fibrosis consistent with the patient's history of hypertension. Extensive tubular necrosis is present, indicating acute tubular necrosis. The sections of the thyroid show changes consistent with benign multinodular goiter. The sections of the prostate show glandular and stromal hyperplasia consistent with clinically benign prostatic hypertrophy, negative for malignancy. The sections of the stomach show multiple foci of mucosal hemorrhage indicating acute hemorrhagic gastritis. The sections of bilateral lungs show marked capillary dilatation with extensive pulmonary edema with focal intra-alveolar hemorrhage. However, no hyaline membranes or acute inflammation are identified. Marked autolysis is seen in bilateral kidneys, gastric mucosa and the spleen. The final diagnosis was as follow: Hyperacute and chronic ischemic heart disease with moderate to severe calcific atherosclerosis of the coronary arteries (Main, LAD, and RCA) with 40% to 100% luminal obliteration. Mild acute pericarditis. Extensive hepatocyte necrosis with marked steatosis of the liver. Nephrosclerosis and acute tubular necrosis of the kidneys. Multinodular goiter of the thyroid. Glandular and stromal hyperplasia of the prostate. Acute hemorrhagic gastritis. Multiorgan congestion, especially in the lungs and spleen. From the final autopsy summary, it was reported: "This patient is a 70 year old male with a history of hypertension, hyperlipidemia, gastroesophageal reflux disease, benign prostatic hypertrophy and remote history of gastrointestinal bleeding, who was admitted to the hospital with progressive weakness and shortness of breath for the last few days on 17/Apr/2003. His admission laboratory tests indicate acute liver failure, acute renal failure, and lactic acidosis and possible DIC. The working diagnosis was early sepsis. At autopsy, the histology shows evidence of hyperacute and chronic ischemic heart disease with moderate to severe atherosclerosis of coronary arteries with 40-100% luminal obliteration. There is also extensive hepatocyte necrosis and steatosis in the liver and acute tubular necrosis and nephrosclerosis in the kidneys. Both lungs and spleen show marked congestion. Stress acute hemorrhagic gastritis is also present. The laboratory tests showed progressively increased levels of BUN, creatinine, total bilirubin, AST and ALT with progressive decrease in albumin and globulin with markedly increased BNP (793 pg/mL, suggestive of congestive heart failure) since admission indication multiorgan failure. Despite the negative blood culture (most likely due to the use of antibiotical, the overall finds are most consistent with sepsis with multiorgan failure and superimposed hyperacute ischemic heart disease." "The immediate cause of death is cardiopulmonary arrest secondary to multiorgan failure, most likely due to sepsis. The manner of death is natural."