Age: 15.0
Sex: F
Vaccine: HEP, HPV4, HEP, HPV4
Symptoms: Fatigue, Full blood count normal, Glucose tolerance impaired, Insomnia, Lymphocyte percentage increased
Clinical narrative: Information has been received from a physician concerning a 16 year old female who was vaccinated on an unspecified date with her third dose of GARDASIL (lot# not reported). Subsequently the patient experienced joint pain 2 months after receiving the third dose. The patient's joint pain persisted. She sought unspecified medical attention. Additional information has been requested. This in follow-up to report(s) previously submitted on 4/24/2008; 07/082008 Information has been received from a physician concerning a 14 year old female nonsmoker, non-drinker with coliltis ulcerative,scoliosis, depressive disorder, drug allergy to ZOLOFT aand rotator cuff tear (April 2007) and a history of ovarian cyst, septate uterus and bilirubin increased in 2004, who on 02-NOV-2006, 28-DEC-2006 and 30-MAY-2007 was vaccinated with the first, second, and third doses of GARDASIl vaccine(yeast), respectively (First Lot#653978/0855U, second lot # 654189/0961r and  third lo# 657737/0522U). Concomitant therapy included OTHO-CYCLEN, REMICADE, COLAZAL, iron, albuterol, NEXIUM and LEVSIN. On 06-AUG-2007 at 13:13, the patieny presented to physician's office. In the patient's words "here for bilateral nad/feet pain and swelling.". She now presents with a complaint of joint pain. The onset of the pain has been acute and descibd has been occurring in a persistentpattern for 3 days. The course has been increasing. The pain is described as severe. Joint pain notes: over the weekend started with right foot pain, next day had left foot pain, the following day had pain in her fingers  and both hands and right knee. Visible swelling noted, worse at nightime. Pain was bad enough she was in tears and needed to have her hands wrapped to decrease the pain. Has never had anything like it before. Has a strong family history of autoimmune disease. She has colitis herself. Family history of depression, father has skin cancer, mother has glucose intolerance, sister  has polycystic ovarian syndrome(PCOS) and a half sister with a history of supraventricular (SVT) work up. Lives at home with mom,dad and sister, plys sports , and is exposed to household tobacco. Physical exam was within normal limits except for swelling noted in hands, no redness, no isolated joint swelling, Pain  with finger  flexion, but capable of performing. Blood pressure was 108/78 mmHg,pulse 104 and regular respiartions 18, tempertures 98.1 Fahrenheit and weight 171 pounds. Plan is to start prednisone 20 mg, PO, 3 daily for 3 days,  2 daily for 3 days, 1 daily for 3 days, and additional diagnostic laoratory studies with follow up based on results. Mean corpuscular hemoglobin was 11.4 Hg. On 15-AUG-2007 14:42, the patient presents with complaint of joint pain. In her words, " I have numbness in right thumb, tingling/pain in forehead, swelling/numbness in bilateral feet, which patient states started 2.5 weeks ago."The  onset of pain has been acute and has been occurring in a persistent pattern for 1 week. The course has been increasing . The pain is described as severe. The patient has seen last week for similar complaints and was started on steroids and ran diagnostic labortory tests. Parvo negative for acute infection, sedimentation rat normal,t=rheumatid artritis normal, and Antinuclear antibody negative. She had elevated antistreptolysis-O titers (ASO)Soon 2 months ago for severe sore throat, rapid strep was negative, no culture was done. She was started on penicillin along with steroids. Was to do 60 mg daily for 3 days, then 40, the 20 mg. Mother gave her 30 mg daily because patient wary of side effects Today reports some tingling across forehead and right thumb. No actual numbness, just "feels funny". Reports today that at the time of her joint pain, she had some loose  stools., but no blood. Later in the illness the gatrointestinal (GI) symptoms  worsened but she assumed was the effect of the penicillin. She stopped penicillin and got a BICILLIN shot. Now she is very fatigued and frustrated with the continued pain. She gets relief from narcotic pain medication  she had on-hand. She was receiving REMICADE from her GI specialist  every 3 months. She was given the  option to go without it longer and she chose this option. She was to go back in July., but cancelled because she felt well. Last week was the first episode of  GI complaints and joint pain. She has   never had joint pains with her colitis flares before. Physical exam was within normal limits. Blood pressure was 112/78 mmHg, pulse  88 and regular , espirations 14, temperture 97.4 Fahrenheit and wight 174 pounds. Plan Administered  SOLMEDROL , repeat prednisone for now and then will attempt to maintain with nonsteroidal anti-inflammatories, vitamin B12, and additional diagnostic laboratory studies. On 05-DEC-2007 she was seen in the rheumatology clinic  and received REMICADE Infusion. On 13-FEB-2008 the patient saw the pediatric rheumaologist. She reported that her joint discomfort improved but her ankle discomfort never completely resolved. Over the past couple of weeks, her musculoskeletal discomfort  has been worsening. She was mostly troubled by the bilateral ankle discomfort. She notes swelling and morning stiffness for about 3 hours in the morning and all day discomfort in her ankles. This is particularly troublesome as she jsut recently started  softball (she is the itcher) season and is having difficulty during practice. She takes the CELEbrix without any significant improvement in her symptoms. She had also recently been having increased frequency of bowel movements containing blood but has not lost weight. She has some crampy abdominal pain. Physical exam revealed no interval infections. She denied weilght loss, fever, change in activity, school absences or sleep disturbances. Height 172.4 cm weight  81.9 kilogram  blood pressure 140/65 initially on repeat 1219/68, pulse 88, respirations 22,temperature 36.4 Celcius. Pain rating 2/10 abdomen, 4/10 ankles, numeric scale. Remainder of the exam was within normal limits except for mild abdominal tenderness with deep palpitation  of left lower quadrant. Musculoskeletal system showed her 5th PIPS tahat were reducible. The remainder of the right hand exam was normal. In her left hand she had a trace effusion in PIPS 2-5 with normal range. She had a very suble and reducible flexion deformity of the 4th and 5th PIPS. She had normal ROM of her hips and normal ROM of her knees. She had significant bilateral anle effusions with oain on ROM. She had no toe effusions. She had small tenderness with palpitation of her bilateral Achilles tendon associated pain. Her sacroiliac joints were nottender on palpitation. She had very slighly higher right side of her back than left on forward bending, suggesting a mild scoliosis. Schoberts testing expanded from 10-15 .,5 cm. No leg length discrepancy. Paln and assessment: The patient has ulcerative colitis with active arthritis. She was  most symptomatic in her ankles and her ankle effusions are interfering with the ability to play softball. I understand taht her GI physician intens to change her infliximab infusions to every  6 weeks. Her last infusion was approximately 10 weeks ago. This may help with cointrol of the arthritis. To provide more immediatesymptom relief. I performed bilateral ankle injections. Anestsia was provided  with topical EMLA and topical ethyl chloride spray. Using a 21 gauge needle. I injected  10 mg of ARISTOSPAN and 0.5 ccbupivacaine into each tibiotalar joint. She tolerated the procedure well and actually noted significant redution of her ankle pain almost immediately after the procedure. She will return to see us at which time we will assess whether taht sominfliximab is controlling her symptoms. On next visit  we would consider obtaining a scoliosis series to follow her mild scoliosis. Daignostic laboratory studies included C - reactive protein high sensitivity, automated blood count aspartate aminotransferase, total bilirubin all within normal limits except for the lymphocyte 43% and segmented neutrophils 42%. On 21-FEB-2208 at 15:02, Patient's presents with complaints of faigue, no energy, pain in legs and arms, feel like dead weight, and having low back pain that started this morning. She is here with her mother with complaints of extreme fatigue. Her mother states she received  REMICADE and hydrocortisone last week and had done fairly wel until yesterday.  She does state her ankles have been swelling but that is not anything new. She also received cortison injections in her  ankles last week. She tates yesterday as the day went on she just  started feeling very fatigued and by the end of the day she states she had no energy at all and her arms and legs felt heavy She states she had difficulty sleeping lats night due to an aching sensation in the left mid back that has been fairly constatnt. Her mom states she was also complaining of leg pain bllaterallybelow  the knees a nd still with some ankle pain. There still been some questionss on to whether or not she hasany specific inflammatory disease but there is a possibility of arthritis with her Crohn's disease. She began takin CELEBREX 200 mg capsule(start date and frquency not reported). Physical exam was within normal limits, except for some abdominal tenderness in the left upper quadrant. Blood pressure was 104/60mgHg, pulse 79 and regular, respirations 20, temperature 9700 Fahrenhet and weight 192  pounds. Plan: additional laboratory dignostics and urinalysis . For the unspecified backache. If it does not improve within 72 hours, would recommend a computed tomography with renal protocol. Additional information has been requested.