Age: 78.0
Sex: M
Vaccine: PPV
Symptoms: Diarrhoea, Differential white blood cell count, Dizziness, Fatigue, Flank pain
Clinical narrative: 2/27/19 715p awoke from nap feeling dizzy, nauseated, very weak, muscle aches, Temp 101 degrees, fatigued, unsteady, TYLENOL 500 mg. 2/28/19 symptoms continued. Vomited times 1, shivering and trembling. Right arm sore at injection site R arm, deltoid. Fever controlled w/TYLENOL symptoms waxed and waned. 3/1/19 noticed 2 red swollen areas (R) arm below injection site. The red/swollen areas on right arm were marked with ink along borders to monitor progression of possible inflammation. On 3/1/19 we made a visit to urgent care for evaluation for possible cellulitis. By this time symptoms were beginning to recede. Cephalexin 500mg prescript was given with instructions not to begin unless symptoms progressed. Midnight of 3-1-19, patient awoke profusely perspiring (pajama top soaked wet as well as sheets). His temperature at that time was 98.3 degrees. Patient said he was feeling much better. The fever obviously broke. Patient has been afebrile since his fever broke. Fevers ranged from 101.2 - 99.0 over the 3 days he was ill. (2/27/19 - 3/1/19). He still tires easily but is alert, strong gait, more energy (Sun. 3/3; Mon 3/4). Clinic Dr. is patient's doctor who evaluated him on 2/18 via clinic visit. Blood work (CBC, comprehensive metabolic panel) was included in evaluation. Pulmonary clinic was also notified of possible adverse reaction as patient received #23 pneumococcal polysaccharide valent vaccine, right deltoid on Wed. 2/27 (a day after receiving the SHINGRIX vaccine Tues. 2/26) at pulmonary clinic visit. The swollen/red areas of upper right arm (same arm he received both vaccines) have receded and continues to return to normal as of today 3-4-19. No antibiotic needed. Over last 3 days (3/2, 3/3, 3/4) patient has complained of left side pain at location of waist radiating to lower back and upwards towards chest. Relieved with EXTRA STRENGTH TYLENOL and sitting upright. Pain receding today 3/5 (muscle strain from retching when he vomited 2/28?) kidney injury? After fever broke, patient voided urine had foul odor. That resolved 3/2 with increased fluids and dietary intake. Concerned that this severe reaction might have been caused by having two different vaccines so close. Patient also developed a smattering of small red "pimples" mid anterior chest (breast to breast). Temp at that time was 96.9 degrees, P 72. Denied itching or pain from these "pimples". Monday 3/4 cluster of chest pimples looked like they opened and scabbed over. No visible drainage. Again denies pain, burning or itching of this area. Could this be a subclinical case of shingles? On Sat and Sunday 3/2 and 3/3 patient had multiple small loose stools which subsided by Mon. 3/4. No blood noted in stools. Question: Can we expect another adverse reaction to dose #2 of SHINGRIX scheduled to be given the last week in April? What would be the recommendation to avoid this reaction from happening again? Concern: I am wondering if patient's immune system became overwhelmed by having these 2 vaccines so close together. He has stable metastatic melanoma diagnosed March 2017. Received 14 infusions of Pembrolizumab. Last infusion was March 23, 2018.