Age: 68.0
Sex: F
Vaccine: HEP, HEPA, PPV, TYP, YF
Symptoms: White blood cell count normal
Clinical narrative: The patient is a 69-year-old female with a history of hypertension and restless leg syndrome. She also had been diagnosed with fibromyalgia, although she stated she did not believe the diagnosis and felt she more likely had rheumatoid arthritis (RA), due to her family history. She was evaluated in travel clinic on 25 August 2014 in preparation for her medical mission trip. She received the five vaccines: hepatitis A, hepatitis B, typhoid (left arm) and PPSV23 and yellow fever (right arm). She reports a history of fever, chills, profound weakness, severe fatigue, myalgias and arthralgias with onset within one day post vaccine receipt. Reported the day after vaccine receipt at approximately noon and she developed fever, mild headache, and by 4 PM she reported experiencing a high fever (not measured), malaise, weakness, severe myalgia, stiffness and arthralgias. She stated the symptoms were severe for 4 days, and then the fever and chills resolved, however the fatigue, weakness, myalgias and arthralgias with stiffness continued. The symptoms were more severe between her knees and the tops of her thighs, lower buttocks but did not include hips. She stated her symptoms were symmetric although more pronounced on her right side. She also stated she had weakness and pain to her upper extremities especially bilateral shoulders, and had difficulty lifting her arms due to weakness, pain and tightness across her shoulders and upper neck and weakness in her hands. Her sleep was affected with hourly waking due to difficulty positioning herself, and discomfort. She has had difficulty with ADLs including dressing herself, and reaching for objects, getting in and out of chairs and toileting. The fatigue was overwhelming and she still requires energy planning and naps during the day in order to function. She described a large local reaction on her left arm, which was erythematous, extended almost to her elbow, and then turned ecchymotic. It lasted over a week. It was pruritic, and warm to touch, but no urticaria, scale, vesicles or pustules and then resolved spontaneously. She had no paresthesias, or paralysis. She had no night sweats, and no further fevers. She states about 2 weeks after onset she saw her primary care provider who provided reassurance. She saw an orthopedist for a previous issue related to rotator cuff tear, who examined her and found no abnormalities in her knees. She had an MRI of her (R) shoulder which demonstrated a torn labrum, superior supraspinatus tear and severe RTC tendinopathy. She has had several follow-ups with internal medicine and had extensive workup including chemistry CBC immunology markers, serum protein electrophoresis, inflammatory markers, RA factor, MRI of the head and spine, and her evaluations were negative. She was seen by neurologist at clinic and had an EMG pending, but then made the decision to be evaluated by another Dr. who is with neurology at another facility. Dr. ordered EMG which was WNL, and his clinical opinion was that she had normal strength and mobility and was without evidence of disorder. She received chiropractic care which was not helpful. She states her lab evaluation was normal except for low vitamin D. She then was evaluated by rheumatology who diagnosed her with polymyalgia rheumatica, atypical presentation. She was given a course of steroids which provided significant improvement within 24 hours, and symptoms immediately worsened after taper completed. She has resumed oral steroid therapy. She also received PT and it has helped to regain some strength. She did go on their schedule mission trip, on 14 September 2014 and had continued symptoms and difficulty due to severe fatigue. She did not take her malaria medication. She also had participated in travel in the previous year. Neurology: normal exam, normal EMG. Rheumatology #1 on 11 Dec 2014: dx unspecified polyarthropathy or polyarthritis, myalgia and myositis, vit D deficiency and fatigue. POC complete neuro eval, r/o RA, PMR, inflammatory myopathy. PM/DM unlikely. Comment of: "more distal weakness than proximal weakness which is not classic for PMR." Rheumatology #2 on 06 MAR 2015 polyarthropathy or polyarthritis. Polymyalgia rheumatica, chronic, moderate, atypical presentation with proximal and distal involvement and elevated ESR.