Age: 14.0
Sex: F
Vaccine: HPVX, TDAP
Symptoms: Antinuclear antibody negative, Anxiety, Arthralgia, Bacterial test negative, Blood creatine phosphokinase normal
Clinical narrative: This case was reported in a literature article and described the occurrence of meningococcemia in a 17-year-old female patient who received dTpa vaccine. Co-suspect products included HPV vaccine. Previously administered products included HPV vaccine (1st and 2nd dose). Concurrent medical conditions included condom and heterosexuality. On an unknown date, the patient received dTpa vaccine at an unknown dose and the 3rd dose of HPV vaccine. On an unknown date, unknown after receiving dTpa vaccine and 1 year after receiving HPV vaccine, the patient experienced meningococcemia (serious criteria hospitalization and GSK medically significant), painful rash, headache, malaise, polymyalgia, arthralgia, anxiety, discomfort and petechial rash. The patient was treated with ceftriaxone and meningococcal vaccine. On an unknown date, the outcome of the meningococcemia, headache, malaise, polymyalgia, arthralgia, anxiety, discomfort and petechial rash were recovering/resolving and the outcome of the painful rash was recovered/resolved. It was unknown if the reporter considered the meningococcemia, painful rash, headache, malaise, polymyalgia, arthralgia, anxiety, discomfort and petechial rash to be related to dTpa vaccine and HPV vaccine. Additional information received: This case was reported in a literature article and it described the occurrence of chronic meningococcemia in a 17-year-old female patient who had received an unspecified Tdap and unspecified HPV vaccines (manufacturers unknown). She had no history of sexually transmitted infection, was in a monogamous heterosexual relationship and reported to usually use condoms. She denied any exposure to animals and had not traveled beyond her local area. She did not attend college, but stayed overnight once or twice a month with her boyfriend who lived in a college residence hall. No further information on the patient's medical history, concurrent medical conditions or concomitant medication was provided. On an unspecified date when she was 14 years old she received an unspecified Tdap (dosage, administration route and site unknown; batch number not provided). On unspecified dates between 14 and 16 years of age she received 3 doses of an unspecified HPV vaccine (dosages, administration routes and sites unknown; batch numbers not provided). On an unspecified date, approximately 1 year after the last vaccination, the patient developed a painful rash on her hands and feet accompanied by headache, severe malaise and generalised myalgias but no fever or chills. She described the rash as barely noticeable but very painful. The symptoms disappeared spontaneously after 3 days and she was well for the following 2 weeks but she had a second episode. She reported it to be more painful both at the site of the skin eruption and in the joints of her wrists, hands, ankles and feet. Her primary care physician diagnosed her and treated her for contact dermatitis. The symptoms improved more slowly this time with compete resolution over 1 week. She suffered a third recurrence a week later and it was so painful that she sought medical advice immediately, was treated symptomatically and gradually returned to normal. However she self-referred herself to a hospital eight weeks after the initial symptoms complaining of painful rash, arthralgias and general malaise again. Upon clinical examination she was noted to be afebrile but appeared anxious and uncomfortable. She was found to have 5 small clusters of petechial lesions consisting of 2-10 discrete petechiae each that were intensively painful on palpation (3 on her right hand, 1 on her left arm and 1 on her right ankle). She had no other skin findings and she did not present obvious joint swelling. Her major muscle groups were mildly tender to palpation but her heart, lungs and neurological examinations were normal and she had no splenomegaly. This was a serious case as the patient required hospitalisation. Laboratory test taken during her hospitalisation showed a leukocyte count of 12,000 cells/mm3, of which 67% were neutrophils, 30% were lymphocytes and 3% were monocytes (no normal range provided). Her haemoglobin was 14.5 g/dL and the platelet count was 640,000/mm3 (no normal ranges provided). A comprehensive biochemistry investigations and creatine phosphokinase were normal according to the authors. She had an erythrocyte sedimentation rate of 85 mm/h and a C-reactive protein of 102 mg/L (no normal range provided). Antinuclear antibody and rheumatoid factor were negative. Serologic testing for Epstein Barr virus, human immune deficiency virus and rickettsia was negative. Chest radiography and echocardiogram were normal according to the author. Urine nucleic acid amplification testing for Neisseria gonorrhoea and Chlamydia trachomatis was negative, but her blood culture revealed Gram negative diplococci, later identified as Neisseria meningitidis serotype B on her first day of hospitalisation. Her laboratory testing of the terminal complement components and properdin was normal a week after the hospitalisation according to the authors. Treatment prior to hospitalisation was not specified. She was started empirically on intravenous ceftriaxone on hospitalisation that was discontinued after 5 days when she was discharged from hospital. In addition to this she received a dose of conjugate quadrivalent meningococcal vaccination immediately prior to discharge. The outcome of the rash was recovery after 3 days of antibiotic treatment. The authors reported that the other symptoms had markedly improved by then too. The authors did not comment on any possible causal relationship between the events and the vaccines she had received. The authors concluded that "the first quadrivalent conjugate meningococcal vaccine was approved by the Food and Drug Administration in 2005 and almost immediately added to the universal paediatric and adolescent immunization schedule for all 11-12-year olds. Initially recommended as a single dose vaccine, the Advisory Committee on Immunization Practices added a booster dose at age 16 years in 2010. Because our patient was immunized with both Tdap and HPV vaccines starting at age 14 years, we were surprised that she had not been immunized with quadrivalent conjugate meningococcal  vaccine. Because quadrivalent conjugate meningococcal vaccine capsular types include A, C, Y and W135, prior vaccination would not have prevented her infection from serotype B. In later 2014, approximately 1 year after our patient was hospitalized; the Food and Drug Administration approved the first multicomponent meningococcal B vaccine. Specific advice from the Advisory Committee On Immunization Practices on how to introduce this new vaccine into the population is under discussion."