Age: 38.0
Sex: F
Vaccine: HEPA, TYP, YF, HEPA, TYP, YF
Symptoms: Headache, Hypoaesthesia, Injection site pain, Muscular weakness, Nuclear magnetic resonance imaging
Clinical narrative: Initial report was received 31 March 2009 from a health care professional, who also submitted this report to VAERS (Temporary VAERS E-Report Number E-28864). A 38-year-old female patient with a past history of eczema, "icthyosis" and allergies to nuts, crab and sulfa had received a first dose subcutaneous right arm injection of VF VAX, lot number UF431AA, and a first dose intramuscular right arm injection of TYPHIM VI, lot number B0347 (lot number invalid), and a second dose intramuscular left arm injection of HAVRIX (lot number AHAVB275AA, manufacturer Glaxosimthkline) during the AM on 09 March 2009. At the time of vaccination the patient had no known illnesses. The patient recalled that her first injection had been TYPHIM VI and it made her heart feel like it was racing. An unspecified amount of time later (reported as PM) on 09 March 2009, the patient developed injection site soreness and a headache. On 13 March 2009, she developed lower back soreness that extended up her spine. Corrective treatment included Motrin and local heat, but the soreness continued and she was unable to participate in a ski trip. On 15 March 2009, her back pain improved. On 16 March 2009, the patient had intermittent headaches but was able to ski. While skiing, she had been hit by a snow board on the left arm. On 21 March 2009, her "muscles did not feel as strong". The following day on 22 March 2009, she remained in bed with chills, her hands and feet felt numb, she had tingling in these extremities, her skin was red, and "felt like she had the hives". On 23 March 2009, she experienced numbness and weakness in her left arm, her right hand was numb, and she experienced burning and tingling. She went to the medical center and was told that her symptoms were from the vaccines she received; not the snow board injury. She also developed a "huge sore" on the inside aspect of the left upper arm and requested a referral to a neurologist. Her symptoms worsened that night, then improved in AM, then worsened again on the night of 24 March 2009 and continued through 25 March 2009 at which time she was evaluated by a physician. The soles of her feet and palms of her hands had been red with numbness and tingling and she took Tylenol PM prior to bed on 25 March 2009. She was evaluated by a neurologist on 27 March 2009. She had burning under the skin, redness on the left ear and pain in her back was severe. The patient passed tests for reflexes, strength, and "pokes". The patient stated the neurologist informed her that the symptoms were likely vaccine related and that she could not travel to on 29 March 2009 as planned. On the morning of 28 March 2009, the patient felt better, but by that evening, developed severe back and neck pain which continued until 29 March 2009. The patient called the neurologist and was subsequently evaluated on 31 March 2009. The patient passed all neurological testing, she had blood work performed (tests ordered unknown) and had been scheduled for an MRI of the head on 01 April 2009. The patient's husband hadn't observed any changes in the patient's gait and the patient denied any problems with breathing, speaking or thinking during the course of events; but stated her legs and ankles felt weak. The patient's recovery status was not reported. Follow up information was received on 11 May 2009 from a health care professional who reported that the patient denies egg allergies. The patient did not want additional contact, therefore confirmation of the results were not available. Recovery status was unknown. This case was one from a cluster of two case reports received from the same reporter. The other case has been captured in 2009-01346.