Age: 76.0
Sex: M
Vaccine: FLU3, PPV
Symptoms: Injection site pain, Injection site swelling, Myalgia, Pyrexia, Rash
Clinical narrative: Initial unsolicited report received from a pharmacist on 26 October 2015. This case involves a male patient (age not reported), who was vaccinated with a dose of FLUZONE HD (batch number: unknown, dose, dose in series, route of administration were not reported) in arm and with 0.5 ml dose of PNEUMOVAX 23 (manufacturer: other, batch number: 1026033 expiry date: November 2016) via intramuscular route in arm on 18 October 2015. It was reported that patient had no medical history and no drug reactions or allergies. Patient had received Zolpidem 10 mg, Omeprazole 20 mg, Losartan HCTZ 50/12.5 mg and SEREVENT diskus as concomitant medication. On an unspecified date, after vaccination patient experienced rash underneath both armpits and soreness at the injection site. No laboratory investigations were performed and patient was treated with unspecified treatment as a corrective treatment. At the time of this report, patient was not recovered from the events. List of documents held by sender: none. Follow up information received from healthcare professional on 12 January 2016 and 14 January 2016. 76-years-old patient received PNEUMOVAX in left deltoid and flu vaccine in right deltoid. Past medical history included Arthritis, glaucoma, right cataract, emphysema(moderate), hypertension, cirrhosis of liver due to hepatitis C (liver biopsied 72 plus 03 ) acquired in 1960, gastroesophageal reflux disease, anemia, iron deficiency in January 2006, sinus tachycardia(HCC), diastolic dysfunction, left ventricle in March 2006 (neg myoview July 2006 and negative carotid ultrasound 9/2000 (permerantz), Lung nodule seen on imaging study: stable right lower lobe lung nodule, nasal polyp, esophageal ulcer (mid-esophageal ulcer despite rate acid reflux) in 16 September 2013, splenomegaly (last ultrasonography 26 May 2013), kidney stone, kidney cyst, benign prostatic hypertrophy, hypogonadism male, Azoospermia, erectile dysfunction, multilevel degenerative disc disease, osteoarthritis, superficial spreading malignant melanoma of skin (HCC) in November 2009, cancer of skin, basal cell in 30 April 2012. Trigger finger in 2005, cervical spine disease. Past surgical history included bilateral trabeculectomy, left cataract removal on 13 September 2012, malignant skin lesion excision on November 2009 plus 30 April 2012, other surgical left thumb (left basal joint arthroplasty with MP capsulodesis) on 31 October 2013, cholecystectomy in 1967, appendectomy in 1967, left hernia repair on 13 March 2014, right hernia repair in August 2005, endoscopy last 18 April 2014. It was reported that patient was former smoker 1.50 packs per day for 30 years, patient had never used tobacco, and patient did not use alcohol and drug. Patient received concomitant medication as AMBIEN 10 mg tablet from 26 June 2015, 1 tablet nightly as needed for sleep which was ongoing, milk thistle PO take by mouth which was ongoing, SEREVENT diskus 50 (mcg per dose diskus inhaler) 1 puff by mouth twice a day from 12 May 2015 and ongoing, HYZAAR 50-12.5 mg per tablet prescribed as 1 tablet by mouth daily for hypertension from 28 November 2014 and ongoing, PRILOSEC 20mg capsule, 1 capsule every day from 28 November 2014 and ongoing, therapeutic THERAGRAN tablet, 1 tablet by mouth daily and ongoing, cholecalciferol, vitamin D3 1000 unit cap, 1 capsule by mouth daily as needed for prevention of vitamin D Deficiency, ongoing, calcium 500 mg tablet 1 tablet by mouth daily as needed which was ongoing. Patient experienced myalgia and fever after receiving vaccines on 18 October 2015 at local drug store. Patient had developed a confluent red rash of axillae and lower back. The rash was not pruritic. Lab data included Physical examination: blood pressure 120/74 mmHg, pulse 93, oral temperature 99.3 degree Fahrenheit (37.4 degree Celsius), respiration rate 15, body mass index 25.09 kg/m2, peripheral capillary oxygen saturation 98 percent. Other lab data included general: nothing abnormal detected, head, ears, eyes, nose and throat: Normocephalic, Eyes: sclera were non-icteric, Pharynx: clear, Neck: supple, no adenopathy, Cardiovascular: Regular Rate and Rhythm, lungs: Clear To Auscultation throughout, abdominal: positive breath sound, soft, non-tender, no masses, no rebound or guarding. Extension: negative for C/C/E, Skin: there was a confluent erythematous rash of the bilat axillae and a symmetric similar rash around the lumbar were of the back. The rashes were macular (not raised). There was no regional adenopathy; there was slight swelling and tenderness around the injection site of the left deltoid but no induration or swelling. Neuro: Non-focal. Psych:alert and ox3. External colonoscopy on 28 August 2012 DE LO return 2015. Review of systems was negative for chest pain, chest pressure, nausea, vomiting, diarrhea, headache, fever, chills, hemoptysis, orthopnea, dyspnea, hematemesis, melena, bright red blood per rectum, dysuria, frequency, hematuria, any recent gain loss of weight (unexplained). Patient received corrective treatment with TYLENOL for myalgia and BENADRYL for rash. It was reported that patients right arm felt fine and patient felt well overall though did report low grade fever (100) last night. And it was reported that there was still tenderness at PNEUMOVAX site left deltoid.