Age: 23.0
Sex: M
Vaccine: YF, YF, HEPA, TD, TYP, YF
Symptoms: Monocytosis, Nausea, Renal failure, Vomiting
Clinical narrative: Information has been received from the patient's parent who is a physician and from the Centers for Disease Control and Prevention Yellow Fever Work group concerning a 23 year old male patient with no contributory past medical history who on approximately 12/12/03 was vaccinated with a dose of hepatitis A virus vaccine inactivated. Concomitant vaccination on approximately 12/12/03 included a dose of diphtheria toxoid (+) tetanus toxoid and a dose of typhoid vaccine. Approximately two weeks later, on 12/26/03, the patient was vaccinated with a dose of yellow fever virus vaccine. There was no illness at the time of vaccination. The vaccinations were for international travel. Three to five days later, on approximately 12/29/03, the patient developed nausea and vomiting, followed by right flank pain. The patient also developed persistent hypertension (150/100), right lower quadrant pain radiating to his flank and back, as well as anorexia. On 12/31/03, the patient was hospitalized. The initial impression was a kidney stone, but this was subsequently ruled out. Medicine/renal services were consulted for gradual monocytosis, renal insufficiency and hypernatremia. Fluids were adjusted to 1.5 NS, then .25 NS. Urine output was five liters (-600ml from daily I/O). The patient had elevated systolic HTN (160 to 170), which was presumably from a renal etiology. Six days post vaccination, peak TNF alpha was noted. A plan for limited water deprivation test with urine and serum osmolality was noted. On 1/1/04, the patient had an elevated creatinine level. On 1/1/04, creatinine clearance peak was 2.4 and 24 hour urine was 1.8 gm. Monocytosis with cells that were typical monocytophoid were counted at 22% which somewhat abnormal lymphocytes, which the reporter stated was consistent with a measles type of illness. On 1/2/04, a urinary analysis revealed WBCs (mostly monos), 1+ protein, no casts and occasional tubular cells. The hospital sent serum to the Centers for Disease Control lab and the results were pending. The patient did not have jaundice or a rash throughout his illness and did not experience any vomiting of blood. PT was normal. Liver function studies were normal. No kidney biopsy was performed. During hospitalization, the patient received IV normal saline solution (3 to 4 liters in the first 24 hours). Two mornings after admission, serum sodium was elevated to 153 and he was putting out seven to eight liters of urine per day. A nephrologist gave a preliminary diagnosis of diabetes insipidus. Nephrogenic diabetes insipidus was also noted. The IV fluids were changed to dextrose and water and he was given five units of vasopressor. On 1/4/04, the patient was discharged from the hospital. As of 1/6/04, the events were resolving and the creatinine level was approaching normal. As of 1/8/04, creatinine level was 1.4. The last chart entry noted normal monos, normal Na and decreasing creatinine (1.7) with persistent hypertension (150/100). Additional significant labs (dates not reported) included BUN 22, creatinine 1.9 (max), 24 hour creatinine clearance 56 ml/min, lead < 3 mcg/dL, blood culture negative, monospot negative and a non-contrast CT of the abdomen negative. No renal imaging was performed. The final diagnosis was unknown. The reporter suspected a yellow fever reaction of an acute interstitial type nephritis with partial diabetes insipidus. As of 1/9/04, the patient was still recovering.