Age: 1.27
Sex: M
Vaccine: DTAP, MMR, VARCEL
Symptoms: Asthenia, Asthenopia, Body temperature increased, Chest X-ray normal, Discomfort
Clinical narrative: Thursday, December 29, 2011 9:40a.m. 15 mo. well baby check up with Dr. at Clinic. Approximately 10:00 a.m. 3 shots were administered for: DTaP, Chickenpox, MMR. Grandma was scheduled to babysit for sibling and patient Thursday afternoon, overnight and Friday. Mother arrived with the children just before lunch. Mother administered about 1/2 a dose of PEDIACARE acetaminophen to patient at 3 PM. Grandma gave him 3.75 ml at approx. 6 PM. Patient played normally and went to bed in his crib at 8 PM. Grandma checked him at 10 PM and he was sleeping soundly and did not feel hot to the touch. No additional medication was administered. Middle of the night and into Friday, December 30, 2011 patient woke up Grandma around 11:50 p.m. He was making unusual noises that sounded like whimpers and gurgling. Grandma thought he was having a bad dream and listened for him to go back to sleep. She quickly got up to check on him because the noises continued and he sounded in distress. When Grandma turned on the light, she saw patient was lying on his stomach and there was a large (approx 12-inch diameter) wet spot under patient's head. Grandma immediately picked patient up to comfort him and was surprised to see his eyes wide open, bubbles of saliva were emanating from his nose and mouth, he felt hot to the touch and his tongue seemed to be swollen. He was unresponsive to his name and Grandma's pleas to "Wake up, Wake up". Grandma carried patient into the kitchen where there was more light and prepared medication for him but was afraid to administer the medication by mouth for fear he could not swallow. One of patient's hands kept reaching into his mouth and saliva continued to foam from his mouth and nose. His eyes remained fixed and his arms and legs were rigid and fingers and toes were twitching. Grandma woke Papa and told him we had to get patient to the hospital. Grandma called mother at midnight 12 PM, while Papa held patient, and told mother we were taking patient to the emergency room because "something was wrong". Grandma and Papa threw on some clothes and wrapped sibling (4 years old) and patient in blankets and rushed to the car. Sibling was strapped into her car seat but Grandma held patient to make sure he kept breathing during the drive to the hospital. Patient remained unresponsive on the drive to the hospital and did not make any sounds. His mouth remained open and one hand kept reaching into his mouth. His open mouth seemed filled with his tongue. Mother called on the cell phone to get more details and called the hospital about the incoming patient. Grandma talked continuously to patient and sibling for the 10 minute ride to the emergency room. The emergency room nurse opened the locked door and let Grandma and patient in. Grandma informed the staff that patient had received three shots at his well baby check-up on Thursday morning. Then she related the reason we had rushed patient in and described his condition. Mother and father arrived at the hospital (grandma, Papa, patient and sibling were already there). Patient's temperature was taken rectally and registered 104 degrees F. He was awake but not himself - staring. Mother shared this with Dr. and he asked how he would normally react? Mother said "with eye contact-focusing on the person, smiles, acknowledgement". Patient continued putting his hands in his mouth and grabbing at his tongue. Dr. ordered: Urine sample (wanted to catheterize him) mother refused and asked to have him pee on the potty, later a collection bag was attached but no sample was collected. Throat swab for quick strep throat culture-results negative. Chest x-ray (taken from front and side)-results clear. 2 blood draws- results OK-additional results not available for 2-days. Patient was given liquid ibuprofen by mouth at 12:30. He quickly vomited up meds and pieces of oranges. Patient was given TYLNEOL at 12:50 in a suppository. Doctor did not know what to do having never seen this before. He was searching in books and on the Internet and couldn't find anything. Doctor stated this was the first time he had ever seen a reaction to inoculations. Discharge states "fever post vaccination" does not allude to seizure. Patient fell asleep in mother's arms on the examining table and was released at approximately 2 AM. Dr. was confident that the reaction was because of his vaccines and that we could be released without the urine sample. Sibling and patient went back home with Grandma and Papa and slept through the night. Friday, December 30th: Grandma gave patient 3.75 ml of PEDIACARE acetaminophen at approx. 4:30 AM, 9 AM, 1 PM, and 5 PM. Mother gave him 3.75 ml at approx. 9 PM. Weekend December 31 and January 1: Patient tired eyes seems to still be showing discomfort, no real fever, skin cold to touch, some rash on face and shoulder-washed with cool water, screaming, eyes look dull as in tired and still feeling punky, motor grasp a little off.