Age: 53.0
Sex: F
Vaccine: PPV
Symptoms: Tenderness, White blood cell count increased
Clinical narrative: Information has been received from a physician concerning a patient who was vaccinated with a dose of pneumococcal 23v polysaccharide vaccine. Subsequently, the patient developed an injection site reaction and extreme swelling. The patient's outcome was unknown. Follow up information has been received from a physician and from medical records concerning a 53 year old white female smoker (1/2) pack a day) with hypothyroidism, hyperlipidemia, hypertension, and on therapy for menopause, and a history of kidney stones, colonoscopy (August 2005), left ovary removal (2002), bilateral tubal ligation and nausea while on therapy with codeine who on 05-Dec-2005 was vaccinated IM in right arm with a dose of pneumococcal 23v polysaccharide vaccine (lot #650648/0967P). Concomitant therapy included levothyroxine Na (Levothroid), estradiol/norethindrone acetate (Activella), ezetimibe (+) simvastatin and valsartan (Diovan). On 05-Dec-2005 the patient experienced right upper arm pain. On the evening of 05-Dec-2006 she experienced some pain in her right shoulder and arm which progressed throughout the night. The pain was quite severe and not alleviated with any over the counter medication. During the night she also developed some congestion and slight cough. On the morning of 06-Dec-2005 she woke up with fever of 101. She noticed some increasing redness in the right shoulder area. She had no other related complaints, except that she had difficulty moving her right arm secondary to severe pain. She took diphenhydramine hydrochloride (Benadryl) without relief. She also tried icing the area and putting heat on the area without much relief. The patient was seen in the office with a temperature of 100.7. After examining the patient it was decided best to admit her for further evaluation and treatment. It was reported the patient had some slight nausea, no vomiting. Upon admission the patient had diffuse erythema over the deltoid area on the right lateral aspect of the upper extremity, which was exquisitely tender to light touch. She was placed on sultamicillin (Unasyn) 3 g IV q 6 hours and given dexamethasone 4 mg IV q 12 hours. She was given acetaminophen (+) hydrocodone bitartrate (Lortab) 10/500 for pain control. White blood cell (WBC) count was 17.2 x 10^3/ul; hemoglobin 14.1 g/dl, hematocrit 41.0% and platelet count 331 x 10^3/ul. Lateral chest x-ray was within normal limits. At 8 p.m. the patient's temperature was 99.8. She remained afebrile throughout the remainder of her admission. On the morning of 07-Dec-2005 her pain had subsided some, but not significantly. She had no further nausea. Examination of right shoulder revealed continued limited range of motion but slightly improved. The patient had slightly increased erythema and the area was still tender to light palpitation. Sodium was 135 mmol/L, potassium slightly low at 3.4 mmol/L. The patient's white count had increased to 19.6 x 10^3/ul, but this was thought to be secondary to steroid therapy. Dexamethasone (WAES#0601USA03107) was discontinued, and she was placed on ketorolac tromethamine (Toradol) 30mg IV q 6 hours. The patient was kept overnight one more day because the erythema seemed to be slightly progressing. On 08-Dec-2005 the patient had improved significantly  and was felt to be stable for discharge. Her WBC at discharge was 22.1 but again, this was felt to be secondary to steroid therapy. Her potassium had recovered to 3.7 mmol/L. She was discharged with amoxicillin (+) clavulanate potassium (Augmentin XR) 1000 mg 1 PO BID times 7 days, naproxen (Naprosyn) 500 mg 1 PO BID and instructed to hold valsartan (Diovan) but continue all other medications as previously prescribed. The patient's discharge diagnoses included cellulitis right upper extremity, hypokalemia, leukocytosis, and it was felt she had and 'adverse reaction to pneumococcal vaccine. " On 09-Dec-2005 the patient was seen in the office for follow up and was doing much better. She had full range of motion of right arm, and the redness on the lateral aspect of her upper arm was improving as well. She was having some nasal stuffiness but no other complaints. There was no cough. On 16-Dec-2005 the patient was again seen in follow up and all of her symptoms had resolved. No further information is available.