Age: 71.0
Sex: M
Vaccine: PPV
Symptoms: Blastomycosis, Bronchial hyperreactivity, Bronchopneumonia, Bronchoscopy abnormal, Chest X-ray abnormal
Clinical narrative: Information has been received from a certified medical assistant concerning a 71 year old male who on 01-JUL-2008 was vaccinated with PNEUMOVAX (lot # 661899/0519X) 0.5 mL IM in the left deltoid. On 28-JUL-2008 the patient developed pneumonia. Medical attention was sought. A chest x-ray was performed and was positive. The patient was treated with LEVAQUIN and is recovering. Follow-up information was received from a registered nurse via medical records which reported that the patient has a history of high blood pressure, high cholesterol, heart problems, possible mycosis fungoides ascending aortic aneurysm 5.2 cm, colonoscopy (2005), PSA, coronary artery disease, aortic stenosis and chronic rhinitis. The patient's past surgical history included heart artificial aortic valve (2/02), bypass (2/02), prostatectomy (12/00), several skin CA: basal cell and squamous cell since 2005, hernias (1980 & 2001) and colon polyp. The patient presented with rhinitis, upper respiratory tract infection and hypertension at the time of vaccination. On 01-JUL-2008 the patient had chief complaints of fever, runny nose and patient denies pain related to the reason for this office visit. The patient was presented for chronic problems of rhinorrhea, post nasal drainage without sinus pressure/tenderness, acute problem of fatigue and subjective low grade fever without sore throat, respiratory distress, vomiting, diarrhea, rash. Has chronic hypertension, treated thoracic aortic aneurysm for which he receives surveillance from the patient's cardiac surgeon. The patient has a history of prostate cancer for which he received 5 years treatment.  Now released to PCP. History of multiple skin cancer for which he receives specialty care. Lipids were under good control. Seen in COUMADIN clinic. No reports of visual changes, chest pain, shortness of breath, extremity swelling and rash. The assessment and plan included a diagnosis of essential hypertension, hyperlipidemia, chronic rhinitis, minor diagnosis of infection upper respiratory; assessed aneurysm, thoracic aortic as unchanged. Assessed status post aortic valve replacement. Upper respiratory infection was diagnosed and treated. Rhinitis was discussed and nettie pot and MUCINEX was recommended. Concomitant medications included Atenolol, LIPITOR, hydrochlorothiazide, amlodipine besylate. It was reported that the patient's pneumonia started on 07-JUL-2008. On 28-JUL-2008, the patient went to the physician's office complaining of cough and was treated for pneumonia. The patient's chief complaint was cough. The patient denies pain relating to the reason for the office visit. Duration of symptoms was 3 weeks. The patient was presented with a history of spasmodic cough, low grade fever, fatigue, without diarrhea, vomiting, respiratory distress. Evidence of good hydration including urine output. Oral intake at normal level. No current fever. No chest pain. The patient denies hemoptysis. Admitted to cough, sputum production, dyspnea, wheezing. All other review of systems reviewed as negative or not pertinent. Mildly increased respiratory rate 18/min. Rhonchi, expiratory wheezes throughout; crackles at bases. The patient was diagnosed with minor pneumonia. The physician commented reviewed different diagnosis pertussis, pneumonia, viral bronchitis. Administered ZITHROMAX and ATROVENT. Mentioned steroid inhaler versus steroid course if not improving with treatment. On 28-JUL-2008, a chest two view, posteroanterior and lateral radiography/fluoroscopy exam was performed which resulted as follows: On the PA view, there was a faint nodular density overlying the posterior left 8th rib. There also was suggestion of a nodular density seen through the left hear shadow. Neither of these were seen with certainty on the lateral view. Hear size and pulmonary vascularity were normal. Hilar mediastinal structures were normal and stable. Trachea was midline. There was a linear density at the left base. Postoperative changes were noted. Impression: Questionable nodule seen on PA view only. There was a linear density in the left base that was probably related to the pericardial fat pad although it was not definitely seen previously. Areas of atelectasis, pneumonia, or nodules not excluded and would suggest short-term radiographic follow-up. On 05-AUG-2008 the patient was presented for recheck of pneumonia symptoms. It was noted that he has actually worsened symptomatically over the past week, with cough productive of green sputum, decreased exercise tolerance, dyspnea on exertion fatigue, malaise. No chest pain, orthopnea, PND, no skin rash. No change in UOP. The patient was using ATROVENT inhaler which was not improving symptoms sufficiently. Oral intake was okay including fluids. His general appearance was in no acute distress, was fatigued but oriented. All other review of symptoms reviewed as negative or not pertinent. On 05-AUG-2008, a chest two view radiography/fluoroscopy exam was performed which resulted as follows: Heart remained normal in size. Postoperative changes were noted. There was increased infiltrate in the left lower lung. The left upper lung and right lung remained free of acute infiltrate. Impression: Radiographic worsening with increased infiltrate in the left lower lung. The patient was diagnosed with bronchopneumonia and a minor diagnosis of hypoxemia and minor reactive airway disease. Pulse oximetry was 89% on room air, prior to nebulizer treatment (DUONEB). Pulse oximetry after DUONEB was 97% room air. Repeat chest X-ray. If no signs and symptoms of pneumonia, would consider steroid course. Reviewed signs and symptoms of CHF, worsening pneumonia, indications for emergent/urgent follow-up care. Will need follow-up chest x-ray after the treatment with exam, 10 days. Follow-up in two weeks. Patient was given LEVAQUIN, XOPENEX and nebulizers (unspecified). On 11-AUG-2008, the patient was still running a fever and a chest PA and lateral views radiographic/fluoroscopy exam was performed which resulted as follows: There was a stable left lower pulmonary opacity. No pleural fluid. No pneumothorax. Heart and pulmonary vascularity were within normal limits. Changes of prior median sternotomy, coronary artery bypass and heart valve replacement. Impression: Stable left lower lobe pneumonia. Follow-up until clearing was recommended. On 12-AUG-2008 the patient had chief complaints of continued cough, fever, etc. The patient was presented for follow-up on pneumonia. Patient denied pain. The patient admitted to fever, chills, decreased appetite, malaise and fatigue. The patient admitted to cough, sputum production, dyspnea and wheezing. The patient was presented for recheck. He stated that he is no better than last week. Still with dyspnea, cough, wheezing, productive nature to cough, fever to max 101.5, significant fatigue. Has now had back to back antibiotics courses. No rash, hemoptysis, nasal congestion, no report of change in UOP, no acute respiratory distress. The patient appeared fatigued, moderately ill, but oriented. Behavior and affect appropriate to situation. Respirations were 18/minute Pulse oximetry was 93% room air. Rhonchi and expiratory wheezing, throughout. Dullness to percussion LLL. No IC subcostal retractions. Assessment adn plan pulse oximetry was done - reviewed indications for admission and supplemental oxygen. Reviewed chest x-ray persistent infiltrate- no change. No effusion or mass seen but this could be masked on chest x-ray. Increased LEVAQUIN to 750 mg dose. Chest CT to rule out abscess/post obstructive pneumonia due to mass and evaluate chest for contribution to symptoms-aneurysm, etc. Steroid course and nebs for reactive airway changes. Follow-up in two weeks unless symptoms worsen. If symptoms not improving and pending CT results, will refer to pulmonologist for evaluation/treatment. The patient was given Prednisone and LEVAQUIN. On 25-AUG-2008 the patient a computed axial tomography exam of the chest with IV contrast was performed for persistent pneumonia. The impression was there are bilateral lung infiltrates, most pronounced in the left lower lobe. Some of the airspace infiltrates have a somewhat nodular appearance to them, but given the multifocal distribution and the fact that the prior study performed in January of 2008, demonstrated no abnormalities this would make an infectious or inflammatory process most likely the etiology. The possibility of underlying neoplastic process is not excluded but is considered less likely. Follow-up exam to document resolution was recommended. On 29-AUG-2009 the patient had an office visit to go over CT results. Patient denied pain relating to the reason for his office visit. The patient was presented for recheck related to persistent pulmonary infiltrates. Reported some increase in strength, cessation of fever and some improvement in wheezing and cough since last visit and abx. No rash, no vomiting, diarrhea, no URI symptoms and no respiratory distress. Assessment included reactive airway disease. Assessed bronchopneumonia organism as unchanged. Reviewed CT scan results with patient and differential diagnosis including resistant pneumonia-viral fungal etc. Inflammatory condition such as sarcoidosis; lung CA. A referral was arranged with a pulmonologist. Withhold additional antibiotics for now inhalers to be use as needed. Pulse oximetry was 96% room air. The following labs were ordered for the patient venipuncture, CBC automated and C-reactive protein, medications were reviewed and allergies reviewed. Follow-up information was received from the physician's office. On 07-JUL-2008 the patient developed squamous cell metaplasia and pulmonary blastomycosis. On an unspecified date the patient recovered from pneumonia, squamous cell metaplasia and pulmonary blastomycosis. The physician considered the events pneumonia, squamous cell metaplasia and pulmonary blastomycosis to be life threatening, resulted in persistent or significant disability and an other medical event. A lot check has been initiated. No further information is available.