Age: 33.0
Sex: F
Vaccine: HEP
Symptoms: Hypoaesthesia, Pain in extremity, Venipuncture
Clinical narrative: Etiology: Vaccine-related Left arm pain, BBPExposure, incident reported, with Hep B vaccine indicated           with Position: Dental Assistant oral surgery Allergies: NKDA Medications: none for this injury PMH: Patient reports numbness and tingling in index and middle finger,      has cock-up wrist splint for Rt CTS for past year  (sxs in Rt>Left) Dominant hand - Right S. Right upper arm pain from Left deltoid to axilla to medial elbow, that had onset as injection site mild pain after HepB immunization injection on Dec 4th, then she soon developed associated left arm-pit/axilla pain and soreness with a "ropy" soreness that then followed from the medial elbow up thru the upper arm to the axilla. This developed over 1.5 weeks after her Hepislav B vaccine on 12/4/20. Initial report was delayed and she recalled the first week without pain in her axilla/elbow. She was seen by her PCP and advised to follow-up with HC as potentially related to vaccine on 12/4/2020.  Also during 12/4/2020 visit, venipuncture was attempted 3 times between 2 arms (uncertain as to how many attempts on left). As venipuncture was unsuccessful, she was referred to lab for a blood draw later that same day.   ROS: overall improving and she denies erythema, ecchymosis, numbness, tingling in Left upper arm or forearm.  CTS symptoms, Right index and middle fingers > mild in Left, no weakness in pinch or grip.  O: Exam with neck that is supple, no spasms, Spurling is negative to Rt and equivocal to left with vague pain provoked to left upper arm to forearm, and those symptoms are relieved by gentle axial traction to c-spine.  CTS sxs provoked by Tinel and Phalens to right wrist and mild positive to Left wrist,  Ulnar test is negative by Tinel at Left medial elbow and left Guyon's canal at left wrist, Ulnar neg on Rt. Pinch index to thumb is 5/5 on Rt and Left (median n.) and 5/5 bilat, thumb to 5th fingertip pinch (ulnar motor). Sensation to touch intact, bilat, w 2-pt discrimination intact in all fingers.  Good grip in both hands. Left ARM with tenderness and small indurated lymph node in left axilla, no "ropy" residual extending distally, left medial elbow is tender with mild dedema, no palpable medial elbow node, no antecubital nodes palpable. No signs of skin infection in left upper arm at venipuncture site or deltoid vaccine injection site. Deltoid with no pain and no tenderness on palpation. Right ARM with no tenderness in antecubital aspect of elbow at venipuncture site.  Full ROM in both elbows & shoulders.  A: (1) Potential adverse reaction due to vaccine administration and/or venipuncture to left arm.    (2) BBPExposure incident reported, and that triggered the Hep B vaccine, with no record of HepSAb immunity.    (3) Bilateral Carpal Tunnel Syndrome, Right more symptomatic than left, not related to above.  This adverse event is most consistent with lymphatic system reaction to the injection site and/or the venipuncture site. Lymphangitis and reactive lymph nodes are the likely adverse reactions.   The vaccine content could have been contaminated, which is unlikely, as there is no recall for that Lot # of FDA approved HEPLISAV-B. Skin prep with alcohol wipe was followed per RN/NP report for both the vaccine injection site in the left deltoid and for the left elbow antecubital fossa skin for the venipuncture site.