Age: 1.0
Sex: F
Vaccine: DTPHIB, MMR, VARCEL
Symptoms: Chest X-ray normal, Computerised tomogram abnormal, Contusion, Culture throat positive, Diarrhoea
Clinical narrative: Information has been received from medical records regarding a case in litigation concerning a 12-month-old female with allergies to pertussis, "CEFLA" and DURICEF and amoxicillin who on 15-MAR-2002 (also reported as 12-Mar-2002) was vaccinated in the left leg with a first dose of MMR II. Secondary suspect therapy included a first dose of VARIVAX (lot# reported as "1237C"). Other concomitant therapy included a fourth dose in the right leg of TETRAMUNE (lot# 484-860). On 16-MAR-2002 the patient experienced runny nose which resolved on 20-Mar-2002. On 23-Mar-2002, at about 4 PM, the patient experienced a febrile seizure. She was admitted to the emergency room and appeared groggy. Vital signs on admission included temperature 103.1; pulse 168; respirations 40; blood pressure 130/70. Laboratory and diagnostic test performed included: a normal CBC except for WBC which were 11.3; a chest x-ray which showed no definite focal infiltrates; urine protein of 1+; blood glucose of 122mg/dl; blood creatinine of 0.4mg/dl; and a negative blood culture. The patient was discharged on 23-Mar-2002 on 200mg/5cc of AUGMENTIN. The next day, on 24-Mar-2002, the patient came back to the emergency room at 0910 after having another febrile seizure. On arrival the patient was awake and hot to touch. Vital signs were temperature 103.2; pulse 191; respirations 26. Laboratory and diagnostic tests included; MCV 6.7fl; lymphs 19%; monos 16%; head CT which showed bilateral maxillary sinus disease. She was discharged on the same day. 24-Mar-2002 with AUGMENTIN. Vaccination history includes: PREVNAR on 16-May-2001, 13-Jul-2001, 14-Jul-2001, 15-May-2002; diphtheria toxoid (+) pertussis vaccine (unspecified) (+) tetanus toxoid (16-May-2001, 13-Jul-2001, 12-Sep-2001, 13-Sep-2002); poliovirus vaccine inactivated (unspecified) 16-May-2001, 13-Jul-2001, 12-Sep-2001, 12-Sep-2002; Hib conj vaccine (manuf. unknown) 15-May-2001, 13-Jul-2001, 12-Sep-2001 and hepatitis B virus vaccine rHBsAg (manuf. unknown) 12-Mar-2001, 23-May-2001, 26-Dec-2001. On 15-Apr-2005, at the age of 4, the patient started a series of psychiatric exams for assessment of kindergarten readiness for early admission. It is noted that all developmental milestones were achieved ahead of time. The patient was attentive, communicated appropriately and was compliant during the testing. She was at the 15th percentile for overall readiness. Upon internal review, febrile convulsions were considered to be an other important medical event. Information received on 13-Sep-2001 contained the following abstracted events: 15-Apr-2002-vomiting and diarrhea; 17-Jun-2002-runny nose; 08-Aug-2002-a rash all over the body; 13-Sep-2002-hand foot and mouth disease; 22-Oct02-fever fussy, pulling on the ears, 27-Dec-2002 upper respiratory infection; 02-Jan-2003-runny nose; 09-Jun-2003-pharyngitis; 18-Aug-2003 motor vehicle accident; 26-Sep-2003 pharyngitis; 11-Dec-2003-allergies; 09-Sep-2004-early sinusitis; 19-Jan-2004-green nasal discharge; 19-Mar-2004-skin lesion on nose; 12-May-2004-fever of 100.4; 12-May-2004-nasal contusion; 10-nov-2005-left hand and wrist swelling from a fall; 10-Feb-2006-strep throat; 05-Oct-2006-pharyngitis; 02-Jun-2006-heartburn; 11-Oct-2006-dysuria; 05-Jan-2006-nose bleed. No further information is available.