Age: 13.0
Sex: F
Vaccine: HEP
Symptoms: Laboratory test abnormal, Oedema, Rheumatoid arthritis
Clinical narrative: Approximately 2 days post vax on 5/7/00, she experienced mild sporadic joint pain which did not resolve. A doctor visit was required.  A few days following the 2nd dose, the pt experienced joint swelling. In 7/00 every joint in the the pt's body "blew up". The mother stated that the pt's toes and fingers were twisted. She experienced arthralgias, swollen fingers and stiff elbows. Pains were worst in the afternoon. She had morning stiffness alleviated with walking. Over the next two weeks she began to have problems with both knees and difficulty going up and down the stairs. She experienced considerable difficulty with activity. the pt's mother felt that the pt continued to be symptomatic, worse when it rained in the morning, worse when she was very active. The pt had no fever, rash, abdominal pain, alopecia, mouth sores, chest pain, diarrhea or nausea. On 8/5/00 she was started on Amoxicillin and ibuprofen. On her 8/24/00 follow-up visit with the pediatric rheumatologist, the pt had no improvement in her symptoms, her wrist arthritis had progressed with extension limited to 70 degrees on the right. She had morning stiffness lasting 60 minutes. The pt recommended starting methotrexate and considered the possibility of using etanercept which would be given SC twice weekly. The pt's mother felt that the naproxen had been entirely ineffective. The mother had purchased a number of over-the-counter herbal supplements and also had the pt sleeping on a magnetic bed but felt that the magnetic bed had not provided any relief. Impression: the pt most likely has an acute reactive arthritis. The physician found nothing to substantiate a diagnosis of polyarticular juvenile rheumatoid arthritis. The physician stated that the pt's arthritis may be related to Engerix-B. The physician recommended Relafen. A Rheumatology panel taken on 9/1/00 was within normal limits. On 9/22/00 the pt had a visit with the pediatric Rheumatology. The pt has been taking methotrexate and prednisone. She continued to have fuciform swelling of the proximal interphalangeal joints bilaterally and left wrist swelling which interfered with her violin playing. She continued to have morning stiffness lasting 60 minutes. the pt was re-started on naproxen. The pt's methotrexate dose was increased. The physician stated the polyarticular juvenile arthritis started on 10/8/00. At the 10/17/00 follow-up visit, morning stiffness had decreased to 15 minutes. 11/9/00 physician's visit revealed that the pt's PIP joints were less swollen as was the left wrist. She continued to have morning stiffness lasting 15-20 minutes. She has been using a paraffin bath and was doing some hand and wrist exercises. The pediatrician stated that the pt's arthritis was moderate in severity and possible related to Engerix. The physician stated that the adverse events were disabling/incapacitating, and that the pt could no longer play the violin. As of 1/12/01, the outcome of the events is ongoing. F/U on 4/15/01, the physician reported that the pt continued to have active polyarticular rheumatoid arthritis with persistent swelling of wrist and proximal interphalangeal joints. She continued to receive maximal doses of methotraxate and was also receiving Lodine. The physician was considering TNF (tumor necrosis factor) - alpha blockage. On the current regiment her sedimentation rate was normal. She was still unable to play the violin due to stiffness in her fingers and wrists. On 7/27/01, the physician reported that the pt continued (as of 5/01) to have symptomatic polyarticular rheumatoid arthritis under somewhat better control. Swelling of the wrist had subsided there was full range of motion. PIP joints remained swollen but had good range of motion. Cervical spine lateral flexion was limited. The pt continued on maximal doses of methotrexate and was also taking lodine. On the current regimen her sedimentation rate was normal. She still was unable to play the violin due to stiffness in her fingers and wrist.