Age: 16.0
Sex: M
Vaccine: FLU3, PPV
Symptoms: Metabolic function test, Nausea, Platelet count normal, Pyrexia, Red blood cell sedimentation rate increased
Clinical narrative: Fever, Rigors, Leukocytosis, hypotension 12 hr after 23 valent Pneumococcal vaccine Presented like a Septor Pusm. Culture Negative; DATE OF ADMISSION: 11/17/2007; HISTORY OF PRESENT ILLNESS: Patient is s 16-year-old with a chronic medical condition of autoimmune lymphoproliferative syndrome. He has carried this diagnosis since five years of age. It is manifested by recurrent bouts of thrombocytpoenia and in the past, anemia and leukopenia. Patient has had multiple hospitalizations for complications of this, including blood product transfusions in the past. Patient has actually been doing fairly well this fall. He had an episode of thrombocytopenia with platelet counts under 20,000 that necessitated a course of prednisone in 09/07. He was able to be successfully weaned off of this and with adjustment of his other medications he had been doing well for well over a month now. He was in the office yesterday for his influenza vaccine and pneumococcal vaccine 23-valent. He had Prevnar this summer with a recommended booster dose in three months. Patient developed shaking chills, rigors, and fever to 102 deg last night. He was given 1,000 mg of Tylenol at home and a repeat dose in early morning, approximately six hours later. He continues to have shaking chills, headache, nausea, and body aches; Reason for Admission: A 16-year-old boy with ALPS presented with fevers and hypotension. Hospital Course: The patient was transferred from Hospital for rigors, chills, headache, and hypotension that started after the day after receiving a flu and pneumonia Vaccine. He had also had mild URI symptoms preceding the vaccination but those had largely resolved 2 days prior to the vaccination. The patient has a history of ALPS that was diagnosed at 5 years old and has frequently needed hospitalizations with steroid treatment for approximately 1 month at a time. He is generally admitted for thrombocytopenia and receives IVIG with steroid bursts. His most recent hospitalization was early September 2007 for that reason. He had a splenectomy at 7 years old and is on Cellcept and penicillin. During his current hospitalization, the patient was transferred from hospital to Health Science University PICU where he was continued on the vancomycin and ceftriaxone that had been started at hospital, given IV hydrocortisone at stress dose levels, and a rapid flu test was drawn. The patient was hypotensive at 90/30 and tachycardic in the 120s. He received fluid resuscitation, and dopamine was initiated with significant and rapid improvements. He was weaned from his dopamine after several fluid boluses and maintained good urine output. He was transferred to the standard pediatric floor 11/19/2007 approximately 18 hours after admission when his blood pressures had stabilized, and he had become afebrile. The rapid flu test flu test was positive, so the patient was initiated on Tamiflu treatment; however, once he was delivered to the pediatric floor, he was clinically stable with labs correcting, and Tamiflu and antibiotics were all discontinued when blood culture was negative x48 hours. The patient's white count had corrected to 24 from a high 55.6. His platelets were stable at 360 at the time of discharge. His ESR was elevated at 24, and his CRP was also mildly elevated. CSF had no growth to date x72 hours at the time of discharge. Hydrocortisone was also discontinued at the time of transfer to the standard pediatric floor since the patient had not been on long-term steroid dosing prior to admission. He maintained stable blood pressures and was afebrile. 12/26/07-records received with report for DOS 11/17-11/20/07 DC DX: Clinical sepsis. Hypotension. Fever. ALPS. C/O shaking chills, rigors and fever to 102 last night. Headache, nausea and body aches.