Age: 51.0
Sex: F
Vaccine: FLU(H1N1)
Symptoms: Anti-cyclic citrullinated peptide antibody negative, Antinuclear antibody, Arthralgia, Arthritis reactive, Blood immunoglobulin G
Clinical narrative: 52 y/o nurse who received H1N1 (Novartis) on 5/2/2010. Denies any unusual or prolonged local site reaction. Within 1 week of vaccine receipt, experienced aching pain along ribs and in back which lasted about 1 week. The following week, she experienced pain in both ankles with swelling of her feet and ankles. Foot and ankle pain and swelling lasted through Sep-Oct time frame, with gradual improvement after that. Also, around that time, she noted increased soreness of her insteps which has not yet resolved. Describes as aching sensation and "tightness" and insteps are significantly tender to palpation. Complains of similar type pain at the back of her heel. Around late May-early June, she began experiencing aching pain in her knees, followed by left hip pain, which persisted for a couple of months. At the end of May, she recalls waking up in the morning with tingling in her fingers and hands when her wrist has flexed as she pushing off bed to get up. Within a couple days, she awoke and noted drooling from the right side of her mouth and her right fingers and hand were completely numb. She was concerned that she might be having a stroke, but symptoms subsided shortly thereafter. She later experienced persistent pain in her R) hand/fingers, which was later diagnosed as trigger finger. She continues to have right hand stiffness, especially her right ring finger which sometimes locks up. Upon awakening in morning, it takes awhile to extend fingers completed and to make a tight fist. She notes her fingers loosen with activity and moist heat. Overall, this stiffness has improved a little since December 2010, but she still has tightness and aching of fingers (especially her right ring finger, which takes longer to extend than other fingers and sometimes locks). Around August, patient experienced persistent pain in her left elbow. She sought evaluation for left elbow pain and hand stiffness in August 2010 and was evaluated by Rheumatology in Sep 2010. Elbow pain located over left lateral epicondyle and radiates to promixal forearm. Exam showed no active synovitis of hand joints, with minimal swelling and tenderness of left epicondyle, without warmth, bursa swelling or tophus; exam of knees revealed FROM, without tenderness; hips with FROM, without point tenderness; and no lower extremity edema. She was diagnosed with "arthralgias, rule out reactive arthritis" and treated with naproxen and capsaicin cream applied to left elbow. At Rheumatology follow-up in Dec 2010, exam noted to active synovitis; pain over left lateral epicondyle, worse with left wrist extension and supination. Painful nodule over right 4th flexor tendon had improved. Assessment noted improvement of left elbow pain with capsaicin cream and also noted morning stiffness in right hand: no evidence of synovitis or inflammatory arthritis on x-rays or labs; follow up 3 months. Patient reports intermittent discoloration of knuckles, as well as intermittent paresthesias described as burning pain along medial and lateral sides of calves about 2-4 times per month, lasting for less than 1 hour. Dx: Reactive arthritis.