Age: 47.0
Sex: F
Vaccine: SMALL, SMALL, SMALL
Symptoms: Urine ketone body absent, Urine leukocyte esterase, Urobilinogen urine, Vaccination site inflammation, Vaccination site pain
Clinical narrative: Pain & itching at vaccination site from day 1-3 with severe itching from day 3-6. By day 6-7, pt had local reaction (erythema, heat, swelling, evolving large pustule) extending approximately 5 inches over the upper arm (but without crossing the elbow joint or the shoulder) and no associated axillary or cervical gland swelling. Pt denied fever or chills. By day 7, pt was experiencing severe pain & the onset of systemic symptoms as detailed below: Right arm pain, severity 9-10/10 on the VAS, radiating to shoulder, neck (lateral & back area) & through the entire arm involving the hands & fingers, described as burning with sensations of "numbness" (paresthesia-like). Pain, severity 4-5/10, involving the right leg, back (lower > upper) but not buttocks or in a sciatica distribution. While worse on the right side, generalized myalgias, fatigue & joint stiffness/soreness involving the elbow & shoulder on the right. Difficulty sleeping despite taking acetaminophen at doses of 2000-3000 mg per day. On 1 AUG (day 8), because of the severity of the pain, the pt presented to the clinic where a tense bulla surrounding the vaccination site was noted and mechanically drained (no evaluation of the fluid was done). There was no evidence of secondary infection, satellite lesions or generalized rashes noted. On 2 AUG , she was seen with some improvement in local/regional arm pain, with pain intensity rated as 4/10. On 3 August (day 10), she returned to the clinic for evaluation. The vaccination site inflammation appeared to be improving but the bulla fluid had re-accumulated & the pt complained of headache with continued myalgias and arthralgias (worse on the right side and upper extremity). The pt recalls continued pain at levels of 6-8/10 severity despite taking 2000-3000 mg of acetaminophen daily with vaccination arm pain as the worst, but back pains & generalized myalgias persisting. Itching & burning sensations on the right arm persisted but she noted scab formation. She was advised to take diphenhydramine to control the itching which she used at night but without control of symptoms. On 10 AUG, during a medical visit, the pt was started on KEFLEX for possible cellulitis. Exam noted increased pain at the vaccine site and was noted to have erythema, warmth & tenderness around the vaccine site. This was treated with drainage of the bulla and KEFLEX (planned 10 day course). At that time she reported no systemic symptoms, no headache, no neck symptoms, no musculoskeletal symptoms, no neurological symptoms & no psychological symptoms. Pt had no fever, chills, & adenopathy. No culture of the vaccination site or drainage from the site was performed. By 15 AUG (day 23), after 5 days of KEFLEX, the pt actually felt worse, "like a bad flu" (increased malaise, achiness and very lethargic) but without any upper respiratory symptoms and no fever or chills. Exam noted improvement in the appearance of the vaccine site with decreased pain, no redness and a well formed scab that was about to fall off. On 16 AUG, pt noted a generalized rash over the arms, upper back, chest, neck and with a few lesions on the lower legs. She returned for evaluation reporting a pruritic rash (macular semi confluent erythema with no vesicles) on the anterior central upper chest and both arms. The rash did not appear to be consistent with the typical rash associated with smallpox vaccination at that time. The vaccine site was tender but not warm. The scab to the vaccine site was dry and lifting at the edges. There were multiple patches of resolving erythema on the skin surrounding the vaccine site where tape had been applied and removed. At this time she was planning to leave for a vacation the next day. Rash felt to be mild & possibly secondary to the vaccine, the antibiotic, or combination or increased sensitivity due to the vaccine & the antibiotic. It was felt to be safe for her continue KEFLEX & to take BENADRYL for itching. On 17 August, she traveled by plane. She felt worse and her rash continued to worsen after she took the antibiotic, so she discontinued the KEFLEX. Her husband described the rash as pustular/nodular but without draining vesicles. "Canker sores" inside the lips were also noted and her lips felt swollen, even though her spouse did not see any visible swelling. She noted intense itching and heat of the ear lobes and red bumps on her nose. By 19 August (Day 27), the patient continued to feel terrible with flare of all symptoms and severe itching and sought medical care. Her symptoms were thought to be due to the vaccinia vaccine, possibly confounded by the antibiotics. She was instructed to stop taking BENADRYL and continue taking her antihypertensive drug. She was started on prednisone 20 mg 3 times per day for 3 days followed by a taper schedule as follows: 20 mg 2 times per day for 3 days, 20 mg once a day for 3 days and then 10 mg per day for 3 days. During the first 4 days of prednisone she noted significant improvement with near clearing of the rash and significant improvement in itching. Fatigue and myalgias also improved although she still ranked severity as 5-6/10. When she reached 20 mg prednisone dose per day, she noted worsening again of the rash and symptoms. Her scab remained intact until Friday, 24 August when she accidentally knocked it off while changing the bandaid. The patient had also stopped her hydrochlorothiazide (HCTZ) anti-hypertension medication on Saturday, 25 August. On 26 August, she experienced another flare up of symptoms and contacted Emergency Hot Line. The on- call physician thought that her reactions were possibly due to HCTZ and that perhaps another surge in steroids might be beneficial. The patient went to the Emergency Room where she had x-rays and blood work completed. She was prescribed Naproxen Sodium for inflammation and Hydroxyzine HCl for itching, as well as VICODIN for pain. She was referred to an Infectious Disease Specialist and to follow up with her primary care provider (PCP). On 27 August, the patient visited her PCP who advised to finish her Prednisone regimen, decrease HCTZ (1/2 instead of 1 pill/day), consume DanActive or Activia yogurts daily for probiotic effect, apply triamcinolone acetonide 0.1% to affected skin 2X daily, and follow-up visit on 31 Aug. She was also seen by providers in MED DIV for evaluation of the worsening rash. Prominent symptoms were myalgias, pain/throbbing at the vaccine site and a worsening fine papular, blanching rash on the anterior chest and arms. On exam, the vaccine site scab noted the previous week had fallen off leaving a rough, scarred circle with no drainage. The area around the vaccine site was tender with no mass or fluid collection noted. There was no redness or warmth. Hyper-pigmented patches where tape has previously been applied were present. No axillary lymphadenopathy or tenderness was noted. Her systemic symptoms were thought to be secondary to the vaccinia vaccine possibly complicated by a drug reaction contributing to the rash. She was advised to continue the steroids and antihistamine. She was advised to monitor her blood pressure and contact her personal doctor to discuss either stopping the HCTZ until her symptoms resolved or substituting a different blood pressure medication. The pt presented on 29 AUG with continued symptoms: Right upper extremity pain (5/10 on pain scale). Back pain, with lower right back pain the worst (5-6/10 on pain scale). Fatigue (7/10 - Described as "sluggish...tiring easily". Awakens feeling rested, but within 1/2 - 1 hour, feels tired. Exhausted earlier this week after driving for < 1 hour. Body aches/myalgias (right > left side, 4-5/10 on pain scale); muscle pain worst in the area of shoulders. Arms described as "feeling heavy...like carrying heavy load" with decreased strength in right hand grasp. Alterations in Sleep - Over the past month has been awakening during sleep secondary to pain. With intense pain, patient was awakening every hour. Currently awakens about every 3 hours. Feels this has affected emotions (more labile). Recent onset of intermittent "toothache" (right lower) dental appointment pending. Her current prednisone dose is 1/2 10 mg tablet yesterday afternoon with the taper outlined above. Other medications: TYLENOL 500-1000 mg every 8 hours as needed for pain. Vitamin D 2000 mg daily (Has not taken over past 7 days). Hydrochlorothiazide started in July 23, 2012: 25 mg per day, but her PCP cut the dose by halve, none since 24 Aug 2012. MOTRIN 200 mg as needed for pain (Patient had only taken 2-3 doses over the past 7 days) Patient was prescribed, but had taken VICODIN and Naproxen 550 mg twice daily.