Age: 53.0
Sex: F
Vaccine: RAB
Symptoms: Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin decreased, Blood calcium normal, Blood chloride normal
Clinical narrative: Initial unsolicited report received from a nurse on 10 September 2015 and additional information received on 11 September 2015. This case involves a (age unknown) female patient who was vaccinated with [route not reported] first dose of IMOVAX (batch number J1676-1, expiry date 08 November 2015) in left deltoid on 09 September 2015. Illness at time of vaccination was reported as none. Pre-existing physician diagnosed allergies, birth defects, medical conditions (specify) was unknown. Concomitant medications were not reported. On 9 September 2015, few second following the vaccination patient had experienced pain at the injection site immediately with numbness and tingling in her fingers on her left hand. It was reported that, pain at the injection site immediately with numbness and tingling in her fingers on her left hand. Later that night it progressed to her right arm and bilateral legs that resolved overnight. Patient had no laboratory investigation. Corrective treatment was not reported. The outcome of event was not recovered. List of documents held by sender: none. Follow up information received from a nurse on 16 November 2015. Patient had no known medical history. Past medical history involved malignant neoplasm of breast in 2003 (right breast), tubular adenoma. Patient currently taking prevacid for gastric ulcer. Mastectomy Partial 7-03 (right breast with prior needle localization), Breast Reconstruc, Enlarge Breast with Implant - 4 - 04 (permanent implants bilateral), Breast Left Fine Needle Aspiration 9 April 2010 and Colonoscopy on 12 December 2014. Patient was due to come for second injection. Concomitant medication involved Vitamin D3 1000 units by mouth once daily, Vitamin B 12 1000 units by mouth once daily, NEXIUM, ferrous sulphate tablet 325 mg by mouth once daily, magnesium 250 mg tablet, ondansetron orally, ZOFRAN ODT tablet by mouth every four hours as needed, prometrium 100 mg capsule, vitamin B complex. On an unspecified date, following the vaccination patient experienced soreness of shoulder of left arm, headache and was tearful. Last menstrual cycle was 24 January 2014. On 09 September 2015, patient went to emergency room. Laboratory investigation involved on 10 September 2015: Blood pressure (BP) 126/91, pulse 92, temperature 37.4 degree Celsius, weight 43.364 kg, Bovine Serum Albumin (BSA) 1.36 m2, Body Mass Index (BMI) 18.21 kg/m2. Blood pressure (BP) 126/91, pulse 92, temperature 37.4 degree Celsius, weight 43.364 kg, Bovine Serum Albumin (BSA) 1.36 m2, Body Mass Index (BMI) 18.21 kg/m2. 12 May 2015: Hemoglobin 13.4, hematocrit (HCT) 41.5, white blood cell (wbc) 4.75, RBC 4.53, mean corpuscular volume (MCV) 91.6, mean corpuscular haemoglobin (MCH) 29.6, measurement of hemoglobin and the hematocrit (MCHC) 32.3, Red blood cell distribution width (RDWCV) 13.5, platelet (PLT) 284, Mean platelet volume (MPV) 10.4, NEUTP 64.9, Absolute neutrophil count (ABSNEUT) 3.08, LYMPH P 23.4, ABSLYMPH, 1.11, ABSMONO 0.33, EODINP 4.0, ABSEOSLN 0.19, BASOP 0.8, ABSBASO 0.04. Lab test on 5 December 2007: albumin (ALB) 4.5, TBILI 0.2, ALKPHOS 64, aspartate aminotransferase (AST) 22 and on 27 December 2013 (CA) 9.2, (GLUC) 82, (BUN) 17, creatinine (CREAT) 0.74, sodium (NA) 138, potassium (K) 4.6, CHLOR 102, C02 24, Anion 17m, alanine aminotransferase (ALT) 13. On 23 October 2015: Blood pressure (BP) 104/72, temperature 36.7 degree Celsius, weight 44.906 kg, Bovine Serum Albumin (BSA) 1.38 m2, Body Mass Index(BMI) 19.01 kg/m2. Corrective treatment was TYLENOL and dotarem. Outcome of event was not recovered. Follow-up information received from a nurse on 21 March 2016. No additional information was reported.