Age: 49.0
Sex: M
Vaccine: ANTH
Symptoms: Acid fast stain negative, Activities of daily living impaired, Alanine aminotransferase normal, Anion gap increased, Arthralgia
Clinical narrative: Pt received his 3rd AVA booster on 27 March 2009. Within 8 hours of vaccine receipt, pt noted rhinorrhea. He denies any itching eyes, hives or rashes, difficulty breathing or angioedema. On 28 March, pt's rhinorrhea continued and he also started feeling achy, feverish and was experiencing a nonproductive cough, fever-associated chills, and night sweats. On 29 March, pt's cough worsened to the point it disrupted his sleep. He was also then experiencing constant arthralgias - "every joint ached"; he denies any redness, swelling or increased warmth over joints he reports joint pains resolved after 3-4 days. As a result of frequent coughing, his throat became irritated. On 28 March, pt contacted his PCM by phone and based on his symptom description, a course of CIPRO 500 mg BID was prescribed. Pt initiated the antibiotics on 2 April. On 3 April, pt's temperature was running 101-102 (temperature taken in PCM's office). His cough and sore throat continued to worsen. That evening, he was evaluated by his PCM and was told he had fluid in his lungs. He was treated with IV doxycycline and observed over a 48 hour period. He continued to take his oral CIPRO (He completed the 10 day course). Pt's symptoms of fever, chills, night sweats, cough and sore throat continued to worsen through mid-April. Related to his coughing, around 12 April, pt also experienced hoarseness and vomiting. These symptoms continued through the end of April or early May. Due to his significant discomfort, he was getting very limited sleep. He had minimal oral intake due to his cough, sore throat and discomfort. He was on leave and was not able to perform his usually ADLs. He was essentially on bed rest. Around April 13th and 14th, pt experienced diarrhea x 2 days (3-4 brown, watery stools per day). He also experienced headaches which he attributed to dehydration secondary to minimal intake. The headaches were located behind the eyes an over both temples and described as pressure-type pain ("like a band around my head"). The headaches resolved within 1 week, after his oral intake increased. Pt also developed a left inguinal hernia and exacerbated an existing R) inguinal hernia due to intense coughing. On 14 April, pt phoned PCM describing his symptoms, and his PCM prescribed MUCINEX and LEVAQUIN for a presumed secondary throat infection. Pt initiated these medications on 15 April. On a follow up call to his PCM on 15 April, pt reported a lack of urine output. On 17 April, pt was evaluated by his PCM. At that time, he was weak, his temperature was 102, and he had experienced a 22 lb. weight loss over the past 2 weeks. He was told that his left lower lobe sounded "junky". Thrush was noted on his tongue, as well as white pustules were noted on his throat. Pt was treated with IV ROCEPHIN. On 18 April, pt was seen at ER where he had a CXR and was reported to have crackling in his lungs. He was given a referral to Infectious Disease but because he was military, was instead seen at clinic. On 20 April, pt was initially evaluated by Infectious Disease. By this time, pt's cough was improving, but he continued to have a sore throat, night sweats, hoarseness, and fevers. A chest and neck CT showed nonspecific diffuse lymphadenopathy (no pulmonary involvement), prominent lingular tonsils, and acute left maxillary sinusitis. On 21 April, pt was admitted to clinic for evaluation of possible laryngeal tuberculosis. While hospitalized, pt had a biopsy of his posterior tongue and oral pharynx as well as cultures of his maxillary sinus per ENT. He remained off antibiotics during his hospitalization. After his biopsy, prophylactically placed on course of steroids for potential airway swelling. His subsequent labs showed a WBC elevation to 20, and pt continued running low-grade fevers (<101). On 5/6/09, pt followed up with Dr. who noted pt's symptoms improving, but still had night sweats without significant fevers (<100).     8/24/09 Hospital records received DOS 4/21/09 to 4/24/09. Assessment: Pharyngitis. Latent Tuberculosis. Patient presents with fevers, chills, myalgias, night sweats, cough. Hoarseness, feels short of breath when lying down. Sore throat inhibited PO intake, lost 20 lbs. Yellow thick sputum. Has contact with similar symptoms. Throat erthythematous, pustule tonsillar region, anterior cervical lymphadenopathy. Leukoplakic plaques in larynx, hypopharynx, and tongue.