Age: 53.0
Sex: M
Vaccine: FLU3
Symptoms: Hypokinesia, Pleural effusion, Pneumonia, Pyrexia, Staring
Clinical narrative: 53 y/o male with history of atrial fibrillation (only on ASA) was in his normal state of health on morning of 11/28/2006.  At about 9:30am, patient received Fluzone vaccine (5cc, Sanofi-Pasteur) while at work.  At ~ 10:45am, pt was sitting in a meeting with another peer, began to stare blankly at the peer, and then went into a convulsion/seizure episode and incontinence. At that time, another co-worker noted that pt had a "swollen" tongue/mouth/neck.  O2 via face mask was provided and bystander CPR was performed for ~ 2-3 min. EMS services arrived, found the patient in polymorphic VT arrest. Shock 200J -> CPR -> VT arrest -> Shock 200J -> CPR -> VT arrest -> Shock 300J -> CPR -> Asystole. Pt then given epinephrine x 1 and then atropine x 1, intubated in the field. Pt transferred to hospital.  He was found to be in Atrial Fibrillation, 190s-200s rate and SBP in 110s. Unclear why, but patient was re-intubated on etomidate, vecuronium (possibly due to mental status unresponsiveness). Pt had an ECHO performed, found to have RV/LV dysfunction and global hypokinesis. There was a questionable repeat seizure activity in which the patient responded to Ativan 2mg. A CT head was then conducted demonstrating no acute hemorrhage/bleed. The patient subsequently went int a rapid AFib with a fall in SBP to the 80s. He was given Metoprolol 2.5mg IV x 2, then started on an esmolol drip and transferred to another hospital for further care. Labs from hospital: Trop I 0.018, Myo 474, Ast 124, Alt 108 On arrival, the patient was on esmolol drip w/ SBP 70s.  Esmolol drip discontinued with immediate restoration of SBP to 90s->110s.  At this point ABG: 7.27/43/402/21 on AC 650 X 16 Peep 5 100% FiO2.  Pupils pinpoint, no eyelash reflex, but bilateral LE withdrawing to pain, L babinski up, R no response.  Approximately 30 minutes into hospitalization, patient experienced a tonic posturing (upper extremities curled, lower extremities straightened), was grimacing, had rhythmic contractions of abdominal muscles, and no longer responsive to painful stimuli. He was thought to be experiencing a seizure, given Ativan 2mg with no response, then Ativan 4mg bolus with subsequent response. He was then started on a versed drip. On admission to BIDMC, pt's labs are as follows: wbc 12.1, K 5.6, AST 113, ALT 107, LDH 33, CK 396. On 11/28/06, a stat ECHO revealed ejection fraction of 15% and global hypokinesis. Given the polymorphic VT arrest and rapid AFib events, pt was taken to emergent cardiac catheterization for evaluation. Fortunately, pt had clean coronary arteries and no further intervention at that time. Of note, a CT of his chest indicated bilateral pleural effusions and associated compressive atelectatis. The CT Abd/Pelvis/Head were negative.  Neurology was consulted regarding patient's mental status, an EEG demonstrated encephalopathy but a repeat head CT was negative for bleed. Further evaluation on 11/30/06 demonstrated a normal MRA brain, MRI head.  Since that time, patient has improved in mental state and respiratory status, all drips discontinued and patient extubated on 11/30/06. Patient had an AICD placed on 12/04/06 while in-house. Of note, he had developed an elevated white blood cell count to 12.1, was febrile to 102, and CT chest indicated bilateral pleural effusions. Concern for possible aspiration pneumonia, and patient had been started on levofloxacin and metronidazole for a suspected aspiration pneumonia. Sputum cultures demontrated Haemophilus influenzae growth, metronidazole discontinued and pt maintained on levofloxacin. Patient is now doing well, continues to have some mild agitation. He recalls no events from 2-3 days prior to the vaccination and onward. He does not recall being vaccinated on 11/28/06. Family and patient report that he was afebrile prior to the event.  Vaccination History: Patient does report prior vaccinations. Occupational Health stated that patient reported influenza vaccination in 2004.