Age: 76.0
Sex: F
Vaccine: VARZOS, VARZOS
Symptoms: Abdominal pain, Back pain, Erythema, Herpes zoster, Hip arthroplasty
Clinical narrative: infection; Muscle spasm of back; Postherpetic neuralgia / atrophy of soft tissue of left abdomen in distribution of prior rash/muscle spasms over left paraspinal muscles/purple patches containing few tiny scabs; shingles / rash / pain; hip replacement; lumbar spine surgery for L4-5 fusion and L3-4 decompression; lumbar spine surgery for L4-5 fusion and L3-4 decompression; Information was received on 23-JUL-2019 from a lawyer and the 78-year-old pt via a Plaintiff fact sheet. The pt's concurrent conditions included high blood pressure, high cholesterol, gastrooesophageal reflux disease and thyroid issues. The pt's historical vaccines included diphtheria toxoid (+) pertussis acellular vaccine (unspecified) (+) tetanus toxoid and her historical conditions included chickenpox. Concomitant therapies included atenolol, omeprazole, atorvastatin, levothyroxine sodium and pneumococcal vaccine (unspecified). On 15-MAY-2015, the pt was vaccinated with zoster vaccine live (ZOSTAVAX) in the left upper arm, for prophylaxis (strength, route, dosage schedule, lot number and expiration date were not reported).  On 27-FEB-2017, the pt developed shingles with pain and rash on the left side of her body below her breast, sought medical attention and received treatment with valacyclovir and acetaminophen-codeine. In December 2017, the pt had an infection that required treatment with steroids or corticosteroids. On an unspecified date in 2017, the pt had a hip replacement.  The pt considered shingles to be caused by zoster vaccine live (ZOSTAVAX), no causality assessment for the other events.  Additional information received on 23-JUL-2019 from the physican, via medical records. The pt past medical history included hypothyroidism, osteopenia, deviated septum, neurogenic claudication, barretts esophagus, barium enema with extensive diverticulosis, grade 1 diastolic dysfunction, basal septal hypertrophy and familial risk factor of cancer. The pt's historical procedures included hysterectomy, bilateral foot surgery, bladder cyst surgery and salivary gland stone removal. It was informed zoster vaccine live (ZOSTAVAX) lot number: K019388 and expiration date: 20-JAN-2016. In November 2016, the pt had a lumbar spine surgery for L4-5 fusion and L3-4 decompression On 27-FEB-2017 office visit, the pt complained of shingles, treatment plan included valacyclovir 1 g three times daily for 7 days and acetaminophen-codeine one tablet three times daily as needed for severe pain. On 28-MAR-2017 office visit, follow-up regarding pain after having an episode of shingles in February. She was seen for this last week (27-FEB-2017) and given prescriptions for methocarbamol and acetaminophen with codeine, but the pt reported that the medications that were given to her did not help at all. She found prescriptions from her orthopedic doctor who prescribed that same medications at a higher dose and they worked better, but she was out of them. She reported that she was still having sharp pains and muscle spasms in the distribution of her prior rash. No new skin lesions and the pt requested a prescription of treatment. Physical examination or review of systems was within normal limits except for mild atrophy of soft tissue of left abdomen in distribution of prior rash, mild muscle spasms over left paraspinal muscles, abdominal pain, back pain, muscles aches, tingling and left mid to lower back and abdomen with few erythematous and slightly purple patches containing few tiny scabs, no pustules or vesicles, no bleeding or drainage.  The pt was diagnosed with post herpetic neuralgia, treated with acetaminophen-codeine for severe pain and muscle spasm of back treated with methocarbamol. The outcome of hip arthroplasty, spinal decompression, spinal fusion surgery and infection was unknown. The outcome of muscle spasms, herpes zoster and post herpetic neuralgia was not recovered. Causality assessment was not reported by the reporting physician.   All available medical records will be provided upon request.