Age: 64.0
Sex: M
Vaccine: VARZOS, VARZOS
Symptoms: Autoimmune disorder, C-reactive protein normal, Chest discomfort, Dry eye, Dry mouth
Clinical narrative: March 1, 2007: Patient received the Zostavax vaccination at the office of (Family Practice). March 5, 2007: Patient felt normal for three to four days and then noticed increased thirst, dryness of mouth, swollen tongue with clear/yellow coating on tongue, and dry nose. Patient called doctor and asks if these are common side-effects of vaccination. Patient left message on doctor's voice mail. March 13, 2007: Patient follows-up telephone call with a letter to doctor describing symptoms and enclosed literature on Zostavax down-loaded from the Internet. Patient notices mild numbness and perception of swelling of hands, lips and skin on face, but no swelling was visible. March 30, 2007: Patient visited doctor, an Ear, Nose and Throat specialist and asked him to examine coating on tongue. Doctor recommended brushing tongue to remove coating. March 31, 2007: Patient returned back to doctor's office to show him coating on tongue, plus dry skin. Patient also reported fatigue and slight dizziness. No treatment or medication was prescribed during visit. April 14, 2007: Patient visited dermatologist, about dry skin and mentioned coating on tongue. She prescribed Prednisone and Aquaphor to relieve dry skin. She also examined patient's tongue and said she saw blisters. April 18, 2007: Patient returned to doctor's office and showed him dry skin on forearms and hands, plus clear/yellow coating on tongue. He told doctor be visited the dermatologist on the 14th and she prescribed Prednisone for 7 days and Aquaphor for dry skin. No additional medication was prescribed. April 26, 2007: On the recommendation, the patient visited another doctor for a second opinion. Doctor thought the coating on the tongue could be "thrush" and started treatment with one Diflucan 100mg tablet per days, plus 5 Mycelex-Troches tablets per day for 5 days. May 2, 2007: Patient followed-up with doctor. She saw some reduction in tongue coating and said to continue taking Mycelex-Troches medication. Coating on tongue did not react further to additional medication. Doctor drew blood samples for analysis and called patient on 7 May 2007 explaining that she saw nothing abnormal in the blood report. May 7, 2007: Doctor received a copy of blood analysis and recommended I see doctor for a biopsy of the coating  on the tongue. He said he suspected Sjogren's syndrome or Auto-Immune disease since patient symptoms were similar. May 16, 2007: Patient visited doctor and asked him to examine the tongue. Doctor did not take any tongue samples but recommended I see doctor, an Infectious Disease physician. Doctor examined patient's tongue, plus took 5 vials of blood for a comprehensive analysis. Doctor called patient on 21 May and said patient did not have Sjogren's because the blood report was normal. A copy of blood report was sent to doctor. May 30, 2007: Patient asked doctor for a referral to Rheumatology Department  for a diagnosis since no one could diagnose the patient's illness. Doctor concurred and contacted hospital, faxed medical records, and asked for them to examine patient. Patient is scheduled for an appointment in Jul 2007. June 10, 2007: Patient's current health is as follows: - Coating on tongue and inside of mouth, - Dry, pasty, and bitter taste, - Thirty majority of time, - Mild numbness and feeling of swelling and stiffness of hands, lips, and skin on face, but no swelling is apparent, - Dizziness/swimmy head feeling.  07/23/2007 MR received for several office visits beginning 3/1/2007 through6/7/2007. Cardiac consult included. OV 3/31/07 for lab work.  No other c/o. OV 4/18/07 with c/o "spots" on his tongue, thirst, and scaley rash on arms. DX: Glossitis. Several TC's 5/2007 with c/o dry nose, mouth, and eyes and yellow tongue. Refered to Rheum to r/o Sjogren's. OV 7/6/07 w/ reports of persistant dry eyes, dry skin, numbness and tingling of fingers (bilat) and chest tightness).  DX:  Paresthesia.  Dry mouth.  Cardiac consult 7/9/07. Follow-up: July 5, 2007: Patient visited hospital for appointment with Dr. in the Department of Rheumatology. Dr. examined patient and checked size of veins and arteries near finger nails. His staff extracted blood for lab testing. He recommended I take a heart stress test. July 12, 2007: Dr. called with blood test results. He said one reading was "high" (i.e. anti-cardiolipin but he was not sure how high above the normal range it was since the lab did not provide the normal range. He said he requested range information and would call me when he receives it . Other blood readings were normal. July 13, 2007: Patient visited Dr. Cardiovascular Disease specialist. He performed an EKG and ordered a treadmill stress test. Patient took treadmill stress test and passed. Patient spoke with Dr. regarding the Lot # for the Merck "ZOTAVAX" vaccine. Lot # for injection given on 1 March 2007 is 0015U. Package product # is 496300. July 16, 2007: Dr called to discuss the high anti-cardiolipin reading. He said the normal reading is around "21" or below and my reading is "25". He said the high reading may indicate early stage of Lupus or Sjogren's Disease. He said that the ZOSTAVAX vaccination may have triggered my auto-immune response since this problem materialized several days after receiving it. He prescribed EVOXAC 30 MG three times a day and wants to see me again in three months. If my tongue continues to have the yellow coating, he will take a lip biopsy. He will perform another comprehensive blood analysis in October 07. July 17, 2007: Patient's current health is same as described above on 10 June 2007. 1/11/2010 Dryness and bitter taste in mouth; dry nose making it very difficult to breath. Muscular stiffness (generally, plus hands and feet). Slight numbness in hands and feet. Tightness around chest (heart test ok); currently investigating pulmonary factors. High anti-cardolypin reading of 25.