Sex: M
Vaccine: PPV
Symptoms: Colonoscopy abnormal, Condition aggravated, Diarrhoea, Diarrhoea haemorrhagic, Flow cytometry
Clinical narrative: He was then given the Pneumovax-23 vaccine and was retested 6 weeks later, which showed that he still only had protective titers to 3 of 14 serotypes; This literature marketed report has been received from the authors of a published article titled as stated below concerning a 19-year-old male patient with growth hormone deficiency and asthma. No information was provided regarding the patient's concomitant medications. On an unspecified date, he presented to his gastroenterologist with large-volume watery diarrhea. Four months prior, the patient was diagnosed with ulcerative colitis (UC) via colonoscopy, which revealed Score 3 pancolitis, and he was being treated with prednisone and infliximab. Stool testing was negative for Escherichia coli but revealed Clostridium Difficile Infection (CDI) (his third episode in 4 monthsthe previous two were treated with oral vancomycin). Thus, a decision was made to undergo FMT. Six days later, commercially sourced stool was placed in the cecum via colonoscopy; endoscopy again revealed severe pancolitis. Given the level of inflammation shown on colonoscopy, it was concluded that the patient was responding poorly to infliximab and he was switched from infliximab to tofacitinib and vedolizumab 8 days status post Fecal microbiota transplant (FMT). Ten days after transplantation, the patient presented to the emergency department with explosive bloody diarrhea (20 episodes per day) and associated leukocytosis, tachycardia, high-grade fevers, chills, tenesmus, and abdominal cramping. Stool was negative for C. difficile but positive for enteropathogenic E. coli (EPEC), enterotoxigenic E. coli, and Shiga toxin- producing E. coli. The patient received supportive care for 8 days, with moderate improvement. On day 9 of hospitalization, intravenous ciprofloxacin and metronidazole, and oral vancomycin were initiated. The patient underwent colonoscopy on day 10 that revealed Score 3 pancolitis, with pathology showing severe active chronic colitis in the rectum, and descending and ascending colon, and moderate active chronic colitis in the cecum. After 17 days, he was discharged on oral vancomycin, tacrolimus, and a prednisone taper. Blood cultures were negative throughout hospitalization. Two years status post FMT, although he has experienced severe ulcerative colitis (UC) flares, he had no recurrence of CDI. Without the knowledge to his gastroenterologist before transplantation, the patient also had primary IgA deficiency. Immunoglobulin testing in 2014 and repeated in 2015 showed <1 mg/dL IgA with normal IgM, IgE, IgG, and IgG subclasses. The patient had not experienced any severe infections throughout his lifetime, although, according to his mother, he had several mild colds every winter that did not require regular antibiotics. Following hospitalization, laboratory testing was performed to further characterize his level of immunodeficiency. Flowcytometry and CH50 were within normal limits. CD4/8 testing revealed 41% CD8 cells (reference range, 11%30%) and 33% CD4 cells (reference range, 35%60%), leading to a 4/8 ratio of 0.82 (reference range, 1.254.50). The patient received all age appropriate vaccinations and was found to have protective IgG titers to diphtheria and tetanus, but non-protective IgG titers to Haemophilus influenzae type b and varicella. He was found to have protective titers to 3 of 14 Streptococcus pneumoniae serotypes. On an unspecified date, he was vaccinated with pneumococcal vaccine, polyvalent (23-valent) (PNEUMOVAX23) (strength, formulation, dose, vaccination scheme, anatomical site of injection, route of administration, lot number and expiration date were not reported) as prophylaxis. Furthermore, the patient  was retested 6 weeks later, which showed that he still only had protective titers to 3 of 14 serotypes (antibody test negative).  The outcome of antibody test negative was unknown.   The causality assessment between the event and pneumococcal vaccine, polyvalent (23-valent) (PNEUMOVAX23) was related.   A copy of the published article is attached as further documentation of the patient's experience.  Literature Report: