Age: 1.03
Sex: F
Vaccine: MMR, PNC
Symptoms: Transaminases increased, Urinary tract infection, Urine analysis abnormal, Viral rash, White blood cell count normal
Clinical narrative: Information has been received from a head nurse concerning a 12 month old female who on 17-JUN-2009 was vaccinated with a dose of MMR II (lot # 663877/0356Y). Concomitant therapy included PREVNAR on 17-JUN-2009. Then "Later that day" on 17-JUN-2009 the patient experienced a seizure and went to the emergency room. The patient was admitted at the hospital (name, address and phone number of hospital unspecified). The patient had a tuberculosis (PPD) skin test on 17-JUN-2009 and the result was unknown. At the time of report, the patient's outcome was unknown. Follow-up information has been received from a physician via pediatric medical records. It was reported that on 14-JUN-2009, the patient was vaccinated with a first dose of MMR II (lot # 663877/0356Y) into her left thigh. The patient was well at the time of vaccination. The physician reported that the patient has an allergy to blue berries and had an excellent history and physical review. The physician stated that the 13 month old female had no previous medical history until 17-JUN-2009, when was admitted to the hospital for a first afebrile seizure. The seizure history began with a day of fussiness and fatigue. The following day, on 17-JUN-2009, she received her 12 month vaccinations of MMR II and concomitantly a dose of PREVNAR. Following these immunizations, she was fussy and was given TYLENOL. Four hours later, she had generalized seizure activity and was taken to the local hospital by the emergency medical system (EMS). She was found to be afebrile and transferred to hospital. During her admission, she had a normal MRI and an abnormal EEG that showed single burst of bifrontal seizure activity. No anti epileptic drugs started at that time as it was thought that the seizure was likely provoked by stress, fatigue, possible viral illness in combination with the immunizations. She remained well until 29-JUN-2009 when she developed a second seizure and was taken to an outside hospital where she was febrile to 101 (but fever resolved before antipyretics given per parents) and diagnosed with a urinary tract infection (UTI). On 29-JUN-2009, a urinalysis test revealed: 1.015; pH 5.5; 10-15 WBCs; 1+ LE; positive nitrite; marked bacteria. On 29-JUN-2009, the urinary culture was later positive for E. coli resistant to AUGMENTIN, BACTRIM, cefepime, cefuroxime and cefazolin, and she was started on SUPRAX on 01-JUL-2009. After this second provoked seizure, she was seen by Neurology and started on KEPPRA on 02-JUL-2009. The patient developed at erythematous papular rash on her trunk, arms and leg after her second dose of SUPRAX and her second dose of KEPPRA. The rash was reticular on trunk and legs, clearing on face (better on 06-JUL-2009 per parents). She remained afebrile. She had no upper respiratory infection symptoms and mildly loose stools. She was seen at our office and diagnosed with a viral exanthema. The rash became more red and confluent and the patient became more fussy and irritable with poor sleep on the night prior to this admission. She had a temperature of 100.4 which resolved with TYLENOL but the irritability persisted. The morning of admission, pt was happier after a 5 hour stretch of sleep but 20 minutes following her dose of KEPPRA, she had another seizure with arm and fist clenching and eye deviation to the right. The episode lasted 3 minutes and she was spacey and fell asleep. She was taken to the hospital and she was found to be febrile to 38.4 and irritable. In the emergency department, labs were drawn and ID was consulted and a decision was made to do an LP because of her irritability. Dermatology was consulted for her rash and neurology was consulted for seizure control. She was admitted for observation. It was reported that on 07-JUL-2009 at 9:30 the patient continued to improve from the rash, which was clearing from the trunk. It was also reported that the physician was confident that "levetiracetam" was not causing the rash. On 07-JUL-2009 at 17:00, it was reported that the patient was good to go home off antibiotics for UTI, except 2 more days on levetiracetam. On 07-JUL-2009, it was reported that overnight, the patient was febrile to 39.1 at noon and 38.1c at 20:00. She was given MOTRIN and defervesced both times. There were no other acute events. During attending rounds, possibility of MMR II reaction was raised. The physician reported that rash "dramatically improved" in the morning of 07-JUL-2009. Trunk almost entirely spared, rash predominantly on thighs and upper arms and lighter in color. Neurological exam was normal, interactive, normal tone and moved all extremities well. Neurology consultation: seizures were provoked; KEPPRA was not necessary at that time. Dermatology consultation revealed findings much more consistent with viral exanthema (SHV617 or Enterovirus) than drug rash. Impression: The patient is a 13 months female with rash, seizures and transaminitis in the context of fever, medications, recent immunization and stress. Per dermatology, virus was most likely etiology. The patient was clinically improving and was stable. Follow up Information was received on 11-AUG-2009 and contained the following adverse experience: viral exanthem (onset approximately 02-JUL-2009). No further information is available. All available medical records will be provided upon request.