Age: 16.0
Sex: F
Vaccine: HEPA
Symptoms: Arthralgia, Difficulty in walking, Erythema, Joint effusion, Joint stiffness
Clinical narrative: Info has been received from an RN concerning a 15 year old white female who on 10/19/04 was vaccinated with a 1st IM dose of hepatitis A virus vaccine inactivated (lot 647994/1234N). It was noted that there was no illness at the time of vaccination. On 10/27/04, the pt developed a rash, joint pain and swollen joints. Unspecified medical attention has been south. At the time of this report, the physician was referring the pt to a Rheumatologist. The outcome was unknown. Follow-up info froma an RN indicated that on 10/23/04, the pt was itchy. On 10/28/04, she had swollen ankles, a rash, joint pain and her elbows hurt. On 10/29/04, the pt's fingers were swollen and walking was painful. On 12/3/04, the pt's redness and swelling was better but it was still hard to open a door and zip a coat. Follow-up info from a physician indicated that on 12/4/04, the pt was seen at a pediatric arthritis center for follow-up of her rash and polyarthritis, which originally developed after her hepatitis A vaccine. The pt was initially seen there on 11/23/04, at which time she was started on a 7-day course of prednisone, which was tapered over the next 7 to 10 days. She was also treated with a 10-day course of Zantac and Zyrtec. On prednisone, the pt said her rash completely resolved. Her joint pain also improved, though it never completely resolved. Now off prednisone, the pt's rash has recurred over the past few days. The pt also continues to have complaints of pain in her toes, ankles, left knee, fingers and wrists. The pt also complains of mild morning stiffness. Her fingers and wrists remain swollen. Fortunately, the pt has had no recent fevers, hair loss, eye complaints, oral ulcerations, chest pain, abdominal pain or Raynaud's phenomenom, which might be suggestive of some other chronic inflammatory disease. Since off prednisone, the pt has been taking ibuprofen 600mg po bid on a fairly regular basis. On physical exam, the pt was a healthy appearing adolescent female, who was in no acute distress. Her BP was 109/60. Her weight was 66.5kg, which was up 1.4kg from her initial visit. Exam of her skin revealed scattered erythematous, raised papules on her back. There was no dermatographia noted. No other rashes were seen. There was no alopecia. Her eyes were clear and symmetric. They were not injected. There was no sinus tenderness to palpation. Her mouth was clear and moist. No oral ulcerations, exudates or erythema were noted. Her TMJ motion was full and symmetric. Her neck was supple with no significant cervical adenopathy noted. She had full and painless motion of her cervical spine in all directions. Her lungs were clear bilaterally. No wheezes, rubs or rales were heard. Her abdomen was soft, non-tender and non-distended. No masses or hepatosplenomegaly were felt. Exam of her joints revealed persistent mild soft tissue swelling of many PIP joints, with a minimal loss of ability to make a full fist. There was no definite swelling of her MCP joints. She had mild soft tissue swelling of her wrists, with a minimal loss of full wrist extension. Her elbow and shoulder motion were both full. She had mild soft tissue swelling of both ankles, but her ankle motion was full bilaterally. She had definite small effusions in both knees, with mild loss of knee flexion bilaterally. Her hip motion was full and painless. The physician also noted that the longer the pt's rash and arthritis persist, the more the physician worried that her disease may be unrelated to hepatitis A vaccine. The physician was beginning to worry that, given the length of her symptoms, the pt might have some type of chronic inflammatory arthritis such as JRA, though her presentation seemed quite unusual. The physician found nothing from the pt's history or on her physicial exam to suggest that the pt had any other collagen vascular disease. The physician went ahead and stopped the pt's ibuprofen. The physician started her on Naprosyn, 500mg, po, bid, to be taken on a full stomach. The physician would see the pt back in 1 month. When if she has persistent athritis, she will be started on methotrexate. The physician planned to repeat lab studies at that time. Follow-up info from a physician indicated that on 1/18/05, the pt was seen back in a pediatric arthritis center for follow-up of her rash and polyarthritis. The pt was last seen a month ago, at which time she was started on Naproxen, 500mg, po, bid, to be taken on a full stomach. Over the past month, the pt has had difficulty with a persistent rash, with some days being much worse than others. "Yesterday", on 1/17/05, the pt described large welts the were "hive-like" and very itchy, mainly on her upper thighs. The pt uses hydrochloride and hydrocortisone cream as necessary for her rash, which does help some. The pt felt her rash was worse with significant cold and heat exposure. In terms of her joints, the pt continues to complain of hand and finger pain. Her other joints do not hurt as much, but she describes persistent joint stiffness, mainly in the afternoon. Naproxen may have helped some, but she felt better on Advil and the pt is now back using ibuprofen, 600mg, po, tid taken as necessary. Other than for her rash and joint pain, the pt says she has felt well. The pt said her appetite remained normal. The pt denies any history of fevers, other rashes, excessive hair loss, eye pain or redness, or any oral ulcerations. She also denied any history of chest pain, chronic cough, abdominal pain, vomiting or diarrhea, episodes of blood in stools or Raynaud's phenomena. On physical exam, the pt was a healthy appearing adolescent female, who was in no acute distress. He BP was 114/62. Her weight was 66.4kg, which was unchanged from her last visit. Exam of her skin revealed scattered erythematous and slight raised areas of rash on her face, trunk, and lower extremities. There was mild deermatographia. No other rashes were seen. There was no alopecia. Her eyes were clear and symetric. Her pupils wer equal, round, and reactive to light. There was no sinus tenderness to palpation. Her mouth was clear and moist. No oral ulcerations, exudates, or erythema were noted. Her TMJ motion was full and symmetric, her neck was supple with nonsignificant cervical adenopathy noted. She had full motion of her cervical spine in all directions. There was no axillary adenopathy. Her lungs were clear bilaterally. No wheezes, rubs or rales were heard. Her abdomen was soft and non-distended. No masses or hepatosplenomegaly were felt. Her extremities were warm and well perfused. There was no clubbing, cyanosis or edema. Her nail bed exam wa normal. Exam of her joints revealed persistent, mild soft tissue swelling of many of her FTP joints. Her MCP joints appeared normal. She was able to make a full fist. Her grip strength was normal. The pt probably also had mild soft tissue swelling of her wrists slightly were prominent on the right side. She had full wrist motion. She did have mild pain with full flexion of her wrists. There were no definite effusions in her knees. Her knee flexion was full. The physician saw no evidence of any arthritis in her elbows, shoulders, ankles, hips or toes. In summary, The pt is now a 16 year old with a persistent rash, which does appear to be somewhat urticarial in nature. She also continued to have mild polyarthritis, but overall the physician thought her joint disease was slightly improved. Given the length of her symptoms, the physician worred that the pt may have JRA, though her pesentation seem quite unusual. The physician again found nothing from the pt's history or her physical exam to suggest the pt has SLE or any other chronic inflammatory disease. The physician questioned if the pt's symptoms were at all related to her prior hepatitis A vaccine. Givent the length of her symptoms, with her rash being her predominant complaint, the physician restarted the pt on a longer course of prednisone, starting at a dose of 30mg, po, bid, for a week, at which time her father will reduce her dose to 20mg, po, for another week, then to 40mg, po, every other day for a week. The physician also placed the pt back on ranitidine hydrochloride, 150mg, po, bid, which she will take on a chronic basis. The pt will also remain on cetirizine hydrochloride, 10mg, po, every day. The physician also discrussed, given the chronicity of her symptoms, the possibly of treating the pt with methotrexate, but the physician decided to hold on this for now. The physician took the liberty of repeating blood work and the pt's WBC was 5300 with 70% polys. 4% eos, 19% lymphs and 7% monos. H/H were lower at 9.9/31.5. Platelet count was 266,000. Her MCV was normal at 85.4 fl. Her ESR was now moderately elevated at 55mm/hr. CRP was only very mildly elevated at 1.8mg/dl. Her ANA was again negative. An ANCA, parvovirus titers (1gG), and Lyme titers were all negative. Her urinalysis was normal and was dipstick negative for both blood and protein. C3 and C4 were both normal at 155 and 26mg/dl. CH50 was also normal at 57U/L. The physician plans to see the pt back in 1 month for follow-up. Additional info has been requested.