Age: 64.0
Sex: F
Vaccine: TDAP
Symptoms: Arthropathy, Cartilage injury, Electromyogram normal, Injection site pain, Nuclear magnetic resonance imaging abnormal
Clinical narrative: Initial information received on 16-Jul-2018 regarding an unsolicited valid non-serious case received from a physician. This case involves a 65 years old female patient who experienced tendinopathy of the left shoulder and abnormality of labrum concerning four tearing minimal, acromioclavicular joint degenerative changes, while she received vaccine ADACEL. The patients past medical history, medical treatment, vaccination and family history were not provided. No concomitant medication was reported. On 12-Feb-2018, the patient received a 0.5ml dose of suspect Diphtheria-2/Tetanus/5 AC Pertussis Vaccine, lot LU5798AB, expiry date 15 Nov 2019 via unknown route in the left deltoid. On 26-Jun-2018, the patient developed a non-serious tendinopathy of the left shoulder (tendon disorder) 4 months 14 days following the administration of Diphtheria-2/Tetanus/5 AC Pertussis Vaccine. On 26-Jun-2018, the patient developed a non-serious abnormality of labrum concerning four tearing minimal, acromioclavicular joint degenerative changes (arthropathy) 4 months 14 days following the administration of Diphtheria-2/Tetanus/5 AC Pertussis Vaccine. On 12-Feb-2018, the patient developed a non-serious generalized tenderness at the injection site (vaccination site pain) same day following the administration of Diphtheria-2/Tetanus/5 AC Pertussis Vaccine. On 02 Feb 2018 and had tenderness at the injection site, patient called back 3 days later and told caller that there was a red spot where she received the ADACEL, patient saw caller on 26 Feb 2018 and there wasn't a red spot at the injection site. Patient had full range of motion and generalized tenderness at injection site. On 04 Apr 2018, the patient went to a Neurologist and had a Electromyograph (EMG) on her left upper arm and it was normal. Patient went back to the Neurologist with pain in her right upper arm on 20 Jun 2018, patient was still having pain in left upper arm. On 26 Jun 2018, patient went to an Orthopedic MD and had a left shoulder MRI, results showed tendinopathy of the left shoulder and abnormality of Labrum concerning four tearing minimal, Acromioclavicular joint degenerative changes. Other relevant tests included- On 04 Apr 2018 had a Electromyograph (EMG) on her left upper arm and it was normal. On 26 Jun 2018 had a Left shoulder MRI- results showed Tendinopathy of the left shoulder and abnormality of Labrum concerning four tearing minimal, Acromioclavicular joint degenerative changes. Final diagnosis was abnormality of labrum concerning four tearing minimal, acromioclavicular joint degenerative changes and tendinopathy of the left shoulder. The patient was treated with TYLENOL 4 x/day and ice left upper arm, TYLENOL and alternate with Ibuprofen and get lidocaine patches for injection site, Gabapentin 1 at bedtime and twice a day with ice. The patient outcome is reported as Unknown for generalized tenderness at the injection site, as Unknown for tendinopathy of the left shoulder and as Unknown for abnormality of labrum concerning four tearing minimal, acromioclavicular joint degenerative changes. List of documents held by sender- none.