Age: 58.0
Sex: F
Vaccine: PPV, FLU3, PPV
Symptoms: Injection site necrosis
Clinical narrative: A flu and pneumonococoal vaccine were administered in the upper left arm on 11/13/02.  The arm became red swollen with pain.  Pt experiened a burning sensation from the elbow and up into my shoulder area.  Returned to the Dr. who administered the shot on 11/18/02 and was told that it was a reaction to the pneumonococoal vaccine.  The arm had developed a large bluish and odd yellowish white blister looking area.  Understand it was not a blister but sort of reminded me of what a small pox vaccine sort of looked like.  No culture was ever taken.  Pt was given an antibiotic and cortisone shot in the hips on this date and began taking 500 mg doses of Cephalexin orally.  Pt was to return on 11/20 for a follow up.  The arm continued to bother pt.  Pt returned to Dr. on 11/20.  Dr. said it looked better (to pt it did not).  Dr. said to return on 11/25 if not better and he would refer pt to a specialist.  Pt was feeling badly and explained this to him.  Pt had a headache and felt weak.  Pt told him pt didn't know if this was from the shots or if it was sinus.  He gave me alegra samples.  Pt felt very weak at this point and spend the day in bed after taking an Alegra tablet.  Arising once to eat some soup.  Around 4-4:30 p.m. Pt called his office to report that pt was really feeling badly.  Pt spoke with his medical assistant who had administerd the shot and again explaned I didn't know what it was but I just felt very very weak.  I was told by the medical assistant that I was thinking to much about the injections.  I assurd her that I would not bother them again.  The following day, I made an appointment at another medical clinic here and saw a CN.  She increased the Cephlaxen dosage to 4 times and instructed me to apply moist heat 3 times a day for about 30 minutes each time.  I was to return on Monday, 11/25.  The office receptionist informed me that the Dr. (CN) I had seen would not be there on 11/25.  So an appointment was made for 11/26.  On 11/25/02, I was feeling very - Nov 12. Called clinic regarding flu shot. I was told that they were only administered during times of the day, during the morning and early afternoon. At the time of my call deadline had already passed and I would have to go in the next day. Nov 13. I went to the clinic at the appointed time that morning. I waited but was told they could not administer the shot until a doctor was there. I was frustarted having taken off work. I waited but no doctor arrived so went back tothe office. When I returned, I signed a release form for the flu shot at the front desk. The copy was very poor and difficult to read. The MD's assistant called me to the pt lobby area. This is where the pts are weighted, temperatures and blood pressures taken before being put in a pt room. i was never placed in a pt romm and never saw a doctor. I thought this was odd since they made such a big deal about having a doctor there before they would administer the shot. The assistant asked if I wanted a pneumonia shot also. I said I had never heard of a pneumonia vaccine and yes, I also wanted it. She administered one shot (Iassumed the flu) vaccine in theupper left arm. She asked where I wanted the second shot. I replied I didn;t care, she said do you want in the same arm? I asked if this is okay and she said it didn't matter. So, I agreed to administer it in the same arm (thinking I would only have one sore arm instead of two). When I left I asked the young jokiingly, if I have a problem, who was I to see, the invisible doctor or who? She said herself. Nov 14-15 I began experiencing periodic burning from the elbow up into my neck area. This was pretty severe burning, the shot area became red, swollen, and hard. I got on the web and it appeared that these symptoms were normal and usually disappeared after a couple of days. on Thursday or Friday, the injection sites began to turn odd colors. A bluish area (like a bruise) appeared in what I think was the injection areas. A yellowish white bliste looking area appeared. It was not a blister but looked like one, it reminded me of a smallpox blister. on Saturday, the 16th, he injection sie was hurting and pretty sore and I decided I had better check with the doctor. I went to the clinic but it was not opened. Nov 18. I went to the clinic and said that I wanted to see a doctor, not one of his staff regarding my injection site. I saw a doctor and he looked at the arm said it was a reaction to the pneumonia shot and that he was going to report it. (I wondered how one could tell which shot the reaction could be from since they...should apply moist heat to the arm 3 times a day for about 30 minutes each time. She increased the Cephalexin to 4 times a day (2000mg/day). She wrote a new prescription for this increased dosage. I was to return to see her on Monday afternoon Nov 25. She would not be in that morning had another commitment. During this visit she explained that if the center of the inflamed area would soften up that it could be lanced but she felt that the body would just absorb the inflammation. A large are around the shot area was very hard to the touch. ...returned home and immediately called to see the doctor explaining that I was feeling weak and she had instructed me to see her that afternoon. She was in and they told me to come on out. Pt husband drove and I saw a doctor who said that the inflammed area had gotten bigger. She said she wanted another doctor to look at it. The doctor looked at it and he said he wanted another doctor to look at it. The doctor was not in and a second doctor looked at it. He said that the reaction could not be predicted. It was agreed that they would run blood work and refer me to a surgeon next door. The blood was drawn and the white count was very slightly elevated. The surgeon was called and he would see me right away. I left their office and went to the surgeons office. He used Novocain to deaden the area and removed the dark brown leathery scab. I was nformed that the wound would require a skin graft, once it was sufficiently healed. the wound was dressed and I was sent home and was to return the following day. Nov 26 Returned to doctor. He removed the dressing and showed me how to soak gauze pads in a saline solution and pack the wound. i was instructed to change the dressing 3 times daily. The wound is about 1 1/2 diameter circle and about 1/2 inch deep. I was to cleanse the wound with soap and water each morning. He wrote me a prescription for a bottle of the saline solution. He provided me with one bottle and a box of gauze pads. I followed these instructions dressing the wound about 4 times a day, since i found it would hurt when the dressing became dry. i was to return to his office on Friday, Nov 29. Nov 27 I awoke and removed the dressing and cleaned it. Some white fibrous tissue appeared to be forming on the wound. I didn't know what this was and decided to call and make sure it was not a problem. I called doctor's office and was told that this was fatty tissue forming and was normal. Nov 29 I returned to the doctor who asked if I was keeping the wound moist. He asked me how often I changed the packs. I said about 4-5 times a day. he said I should keep ot moist and to pay particular attention to the packing at night, since I would be asleep and it was the longest period when it was not receiving attention. He told me I could get more of the saline solution if neede. I left his office and got another bottle of the saline solution and more gauze pads. I was to return to his office on Monday. I made a real effort to insure the packs did not dry out over the weekend. Dec 2 Saw doctor today. He cleansed the wound of the yellow fatty tissue. Was not a very pleasant experience. but there is a good pink tissue beneath this fatty tissue. Arm pretty painful following the procedure. I am to return Wednesday and he will cleanse the wound. May be able to do skin graft end of the week. I asked how long it would be before I could drive off road on the job and he said likely another 7-10 days following the graft. Then would have to be careful not to pump the wound. Will have to wait and see. Dec 3 Arm very sore today. Took 800mg Ibuprofen 3 times for pain. Dec 4 Did not sleep well last night. Soreness got better as this day went on. Saw doctor at 2:30. He again cleansed the wound. Cleansing was much less painful today. He said graft would not be done this week, maybe next. I am to return home on Friday. Dec 5 Went to work at 12:30 today after being up all morning. Felt stronger today and yesterday afternoon as the day progresses. Starting feeling weak around 3:30, left office at 4pm. Had to drive car to dealer for recall repairs. Felt weaker and weaker. Came home dressed wound and went to bed around 5pm. Slept, awoke at 7:30 and was feeling very weak. Arm was hurting on the inside left, painfull to the touch. Stayed up in order to take the last dose of antibiotics. Awoke at 1:20 with bad headache. Took 800 mg ibuprofen typed on computer pretty much he entire 4 hours yesterday at work. Felt like muscle tension pain radiates up the arm across shoulder to my neck and into head. I've worked around 4 hours each day since Monday and have done okay. Returning home and resting in afternoon. Yesterday is the only day I have done so much typing at computer. Will talk to doctor about this tomorrow. Dec 6. No headache when I awoke. Worked morning. Visited doctor today. Temp 99.1. I told him about last night. he said he didn't know, maybe getting flu. I explained that I thought maybe was from working on computer. He said he would be glad to refer me to another doctor if I wanted. I didn't understand where he was coming from. I was just asking about the incident last night. I won't bring up any other questions to him. Can't understand this. He cleaned the wound today (no Novocain used). I am to return Monday. Dec 7-8 Weekend uneventful. Took it easy. Dec 9 First time doctor did not remove any fatty tissue from the wound. He said it was looking good, I was doing a good job in cleansing it. To return friday. Dec 9-10 Worked 8 hours and most of the day Tuesday. Left 45 minutes early on Tuesday, the wound hurting. Kept changing bandage more and keeping the woung moist. Finally, changed the bandage after going to bed earlier and was able to sleep through the night. Dec 11 Worked 8 3/4 hours today. Good day, wound only bothering when dressing dried out. Dec 13 Saw doctor today, arm ready for skin graft. To return on 12/17  Dec 17 Saw doctor, sent to hospital for some pre-ops tests. Dec 20 Entered hospital. Skin graft completed. took graft from upper thigh of left leg. Surgery done as an out-patient retumed home following surgery. Dec 23 Saw doctor, dressing left in place. i am to return on Dec 26. Dec 26 Saw doctor and he changed the dresing. Jan 1 Feeling better more like old self. Jan 5 Saw doctor and he released me. Feb 25 Wound continues to heal but gets these hard tissue areas that sort of split and bleed then disappear and another forms. this has gone on during the last month or so. So, I made an appointment to see a doctor. She says this is Keloid scarring and gave me steroid injections under the scar tissue. She explained I would likely have to return. She did not want to administer shots more frequently than 1 time a month. Wound is still healing. March 31 Arm seems to be better. Hard tissue is minimal now. i have an appointment with a dermatologist in April and think that there is not much more that can be done. Healing is much better than I ever thought possible.