Age: 35.0
Sex: F
Vaccine: HEP, TTOX, TYP, YF, HEP, TTOX, TYP, YF, HEP, HEPA, IPV, TD, TTOX, YF
Symptoms: Arthralgia, Influenza like illness, Jaundice, Liver function test abnormal, Pain
Clinical narrative: Information has been received from a health professional through the Center for Disease Control (VAERS ID 216285) concerning a 39 year old female with an allergy to iodine and no concurrent disease who on 1/21/04 was vaccinated with a dose of hep B virus vaccine. Concomitant therapy included a first dose of yellow fever virus vaccine, a dose of typhoid vaccine and a dose of tetanus toxoid. On 1/30/04, nine days later, the pt developed body aches, a low grade fever, and flu-like symptoms. On 2/2/04 the pt became jaundiced and the following day she developed a diffuse macular-papular body rash. On 2/7/04, four days later, the pt was hospitalized. Her diagnostic tests revealed elevated LFT's. A lumbar puncture was not performed. Test results for CMV, EBV, parvo virus, hep A and hep B were unavailable at the time of this report. As of 2/10/04 the pt was still in the hospital and was said to be improving. On 2/12/04, at the time of this report, the pt had not recovered from these adverse events. No further info is available. Follow up on 03/22/04 states: "On 02/25/04 additional information was received from the CDC.  It was reported that on 02/12/04 the day the pt was expected to be discharged, the pt "took a turn for the worse" as she developed pneumonia and uveitis. Reportedly, the pt was stable at that time, but her liver function tests remained elevated with the ALT approximately 200, AST approximately 100, TB approximately 7 and platelets at 90. The pt continued to maintain a fever of 101 to 102 deg F. The results of two serum samples were both negative for yellow fever.  At the time of this report, it was felt that the test results suggested that the pt's illness may be due to another etiology. The pt's recovery status was not reported. No further information is available." On 04-Mar-2004 additional information was received from the Center for Disease control and Prevention from the minutes of the meeting on 09-Feb-2004. It was noted that this report had been initially considered as a possible case of viscertropic disease. On 21-Jan-2004 the patient was also vaccinated with a dose of hepatitis A virus vaccine inactivated (manufacturer unknown) and a dose of poliovirus vaccine inactivated (unspecified). On approximately 07-Feb-2004 lab results included: AST 129; ALT 564; PLT 149; WBC 11.4. Since 07-Feb-2004 the patient's labs have dropped to bilirubin 7.3 and ALT 377. Tests for hepatitis A, B,C and Epstein-Barr remain in progress. Additional lab results from 07-Feb-2004 included: a serum sample that was PCR negative IgM antibody for yellow fever was positive, P/N 12.7, and yellow fever IgG was negative at 1.0. On 09-February 2004 a serum sample was PCR negative. IgM antibody for yellow fever positive, P/N 14.4, yellow fever IgG was negative at 0.55. The interpreation was that IgM was found, but no IgG. There was no evidence of a persistent virus. Additional information was received on 11-Mar-2004 from the Centers for Diseas control and Prevention that contained updated information obtained during a phone conversatin with the patient and her mother. It was reported taht on 05-Feb-2004, the patient had jaudice and bloody vomiting. On 07-Feb-2004, she had a diffuse maculopapular haemorrhagic body rash (including the palms of her hands), severe abdominal pain and "joint pains polyarticular" and was hospitalized. Between 13-Feb-2004 to 14-Feb-2004 physician's confirmed pneumonia with "ground glass" x-ray (no discrete infiltrate, lungs acunded "clear"). Several antibiotics were ineffective in reducing x-ray abnormalities. She was discharged on 19-Feb-2004 from the hospital and retuned to the hospital on 20-Feb-2004 as an out-patient. She was started on Prednisone because of persisting rash and sever generalized joint pains with swelling of some joints. The patient was admitted to another hospital on 22-Feb-2004 with abdominal pains and high fever and "lots of joint pain". An x-ray "still showed pneumonia and pleural effusion. As of 25-Feb-2004, she was discharged with persisting but "improving pneumonitis", uveitis and severe joint pains. At that time she was still on prednisone. Her symptoms (mainly arthritis) as of 04-Mar-2004 were "slightly worse", as the prednisone dose was being tapered. Additional information received on 11-Mar-2004 indicated that laboratory results performed at the hospital showed platelets 950,000 (now 750,000), WBC 26,000 (on prednisone). LPT's were "very high, but are now back toward normal". Bilirubin was 11.0 at admission to the first hospital, "but now is 1.4 (all as of 01-mar-2004)". A liver biopsy was not completed, but a lung biopsy was done. The results of the lung biopsy are unknown. File to be completed. Other business partner numbers include 200040507. No further information is available. Information for this case was received through an enhanced surveillance program conducted by the Center for Disease Control.  Follow up info was received on 05/20/04: "Further additional information received on 05/06/04 from the CDC, reported that the body rash also involved the conjuctiva. Upon the pt's discharge from the hospital on 02/25/04, she had uveitis with deteriorating vision. Her rash had improved on Prednisone, but was still present at the time of this report. She continues to have symptoms, even on higher dose steriods. No skin biopsy was done. Her vision was getting worse, but was better on steroids. Upon tapering the steroids, the symptoms became worse. The pt had IgM for hepatitis A.  Her hepatitis C status was unknown. On 03/31/04, the hospital lab agreed to send a convalescent serum specimen, which was collected on 02/23/04 to the CDC for testing. No other information was provided at this time. Additional information received on 6/10/04 from the Centers for Disease Control and Prevention reported the patient was vaccinated on 1/21/04 in preparation for a overseas trip. Approximately one week later, she started feeling weak and had flu-like symptoms. On 2/3/04, she started having high fevers, joint pain and became jaundiced. On 2/7/04, she presented to the emergency room with a three day history of jaundice, nausea and vomiting for the previous four days and fever up to 102 degrees F, joint pain and rash. She stayed in the hospital for about two weeks, during which time she developed interstitial pneumonitis that required bronchoschopy. She was discharged on oral analgesics and steroids for severe joint pain. On 2/22/04, she presented to a medical center for severe abdominal pain. She was discharged two days later with the following diagnosis: history of post vaccine YF, resolving; liver function tests secondary to vaccine YF; non-bacterial pneumonitis; myalgias secondary to vaccine YF; fever. On 6/10/04, the patient reported to the CDC that she was currently doing fairly well and was back at work. Her only problem was chronic joint pain in all large joints. She reported that her physician said she had rheumatoid-like arthritis, although her RH reading was normal. Her current medications included steroids and rofecoxib. She reported a previous history of mild arthritis in one hand for the previous four years, but no other problems prior to vaccination. Additional information received on 6/14/04 from the Centers for Disease Control and Prevention reported more lab data. Hepatitis C antibody was negative and a blood culture had no growth after five days. No Lyme results were seen on records. On 2/7/04, the patient had the following test results: ALK Phos 387; Bili total 8.9; Bili direct 4.0; Albumin 4.0; total protein 7.2; YF PRNT 1:10240. On 2/9/04, the patient had the following test result: YF PRNT 1:10240. On 2/22/04 (upon admission to the hospital), the patient had the following test results: AST 159; ALK Phos 195; ALT 207; bilirubin 1.7; lipase 78; Amylase 37; Albumin 2.9; WBC 22,000; platelets 1050. On 2/23/04, the patient had the following test results (taken directly fropm the medical records): EBV to VCA, IgG 8.38 IV (interpretation: 1.00 IV or greater - positive: IgG antibody to EBV Viral Capsid Antigen detected which may indicate a current of previous EBV infection); EBV to VCA, IgM 0.17 IV (interpretation:0 - 0.9 IV - negative: no significant level of detectable IgM antibody to EBV Viral Capsid Antigen); EBV to Nuclear Ag, IgG 4.16 IV (interpretation: 1.00 IV or greater - positive: IgG antibody to EBV Nuclear Antigen detected which may indicate a current or previous EBV infection); EBV to EA-D, IgG H 1.76 IV (reference range: 0 - 0.99, Note: this pattern of the EBV antibodies findings is consistent with a convalescent or past infection. Low levels of antibody to EA can be detected in healthy individuals for years after EBV infection. An unusually high antibody response to VCA or EA in the presence of antibody against EBNA may be a sign of reactivated EBV infection).  Further information is not anticipated, this case is considered closed.