Age: 49.0
Sex: M
Vaccine: TD
Symptoms: Injection site infection, Injection site reaction, Injection site swelling, Insomnia, Palpitations
Clinical narrative: A 49 year old male reported that he received an injection of Tetanus Toxoid Adsorbed, Purogenated on 4/13/00 and the next day, his left arm reportedly, became swollen and infected. He was hospitalized. An ultrasound was performed and reportedly, showed a bone infection. follow up info received on 06/06/2001 indicated that the pt received Tetanus Toxoid Adsorbed. Ultralined lot 4988112 and was hospitalized for 4 days. Follow-up information received on 06/12/2001 as part of litigation proceedings indicated that the pt was seen by the physician an 04/13/2000 because he experienced a left thumb crushing injury. He was administered Tetanus Toxoid, Ultrafined. On 04/17/2000, he contacted the physician's office stating that he had a reaction to immunization and described his arm as red, swollen and painful. He was instructed to self-administer acetaminophen, apply ice and keep his arm moving. He was seen by the physician that day, he was afebrile. On 04/18/2000 he reported to the physician that the redneness improved; he also experienced nausea and was sleepy. On 04/19/2000, he was again seen by the physician. His left arm at his shoulder was very painful, swollem, warm to touch and erythematous with the redness extending to approx. an inch below his elbow on the dorsal aspect. His range of motion was decreased due to his discomfort. A diagnosis of cellulitis post-immunization reaction was made; he was administered intramuscular ceftriaxone sodium for 2 days, then prescribed oral amoxicillin/clavulanate for 7 days. On 04/26/2000, the pt was seen by the physician. His left arm was painful and mildly erythematous with increased swelling at the injection site; intramuscular ceftriaxone sodium was prescribed for the next 3 days. The next day, his left upper arm had developed a warm, firm spot at the injection site approx. the size of two 50 cent pieces; the area was tender to touch and the erythema appeared a "little bit smaller than yesterday." The physician performed a needle aspiration to decompress the area; however, the area felt "pretty' fibrous. On 04/28/2000, the injection site was again visible on his left arm in the region of his deltoid muscle; the injection site was erythematous extending over the entire biceps area, swollen, warm to touch and tender. The pt was instructed to apply heat to the area. His physician prescribed Cefazolin for 3 days to be administered at an infusion facility. The pt was depressed. At the infusion facility, the pt indicated that he had lost 7 lbs., had no appetite and experienced diarrhea for the past 2 weeks. On 04/30/2000, his arm infection worsened; he developed streaking. He was admitted to the hospital for intravenous antibiotics with a diagnosis of 'Type III hypersensitivity,' 'arthus' reaction,' 'serum indurated area measuring approx 4 cm in diameter with 'linear' lymphagitic celulitis measuring approx 6-7mm by 3mm in diameter on his left upper arm; the streaking had lessened from 04/29/2000. His diarrhea had improved. He was treated with cefazolin, acetaminophen and rocecoxib. on 05/01/2000, an ultrasound of his left upper arm soft tissue was performed and showed no sign of abscess or drainable fluid collection in either the superficial or deeper structures. There was diffuse skin thickening overlying the area of induration. There was marked induration and obliteration of te fat planes deep to the area of clinical concern which extended all the way to the underlying humerus and was approx 3cm from the skin surface to the underlying bone. The induration extended to a similar extent to the cranicaudate projections. Citalopram was prescribed. On 05/02/2000, the redness and induration persisted; however, his symptoms were less than on 05/01/2000. Methylprednisolone sodium succinate was prescribed. On 05/03/2000, the pt was discharged from the hospital and prescribed prednisone, cephalixin, citalopram and rabeprazole. On 05/05/2000, the pt was seen by his physician; his left arm extending to his elbow appeared 'ruddy' in color and mile tender to touch. His appetite had increased. He was prescribed propoxyphene napsylate for pain. On 05/10/2000, he was seen by his physician. The physician noted that the pt experienced a red face, some palpitations, hand shaking and urinary hesitancy with dribbling. On 05/11/2000, he was seen by his physician because of continued urinary retention with dribbling. The pt experienced fatigue and did not feel well. On examination, he experienced tenderness over his bladder region. The pt was catheterized for 100cc fo urine. On 05/17/2000, he was seen by the physician. The pt continued to experience 'some' urinary frequency, hesitancy, difficulty urinating, tremore and sleeplessness. On examination, the fibrous thickened area at the injection site on his left arm had improved. Flomax was discontinued; prednisone tapering was initiated. On 05/31/2000, he was seen by the physician. His arm was 'doing well' his urinary symptoms were improving, he experienced a better stream. Prednisone tapering continued. As of 05/16/2001, the pt had recovered. F/U states that the pt reported he had developed blood in his stools for the last few days, "mostly on the paper". A colonoscopy with possible endoscopy were scheduled for 7/6/00. Further follow-up received on 10/19/01, indicated that the pt reported that he had not received a "tetanus shot for approx. the last 8-9 years" and that a few days, post vax, he experienced a flu-like illness with malaise and multiple myalgias and arthralgias. IV cefazolin was initiated on 4/30/01 and over the next 24 hours, the affected area of his left arm seemed to be somewhat less inflammed; however, the induration remained as well as a "central area of fluctuance and inflammation of about 2cm in diameter". The pt still felt "fairly unwell" and was experiencing pain in his arm. On discharge from the hospital, his primary dx was arthus reaction with serum sickness secondary to immunization; his secondary dxs were possible cellulitis of his left arm, depresseion, hyperlipidemia and injury to his left thumb.