Age: 28.0
Sex: F
Vaccine: ANTH, TYP
Symptoms: Protein urine present, Proteinuria, Red blood cell sedimentation rate increased, Ultrasound kidney, Urinary sediment present
Clinical narrative: AD F who was in her usual state of good health in May 2009. Service member (SM) received 2 vaccines in her left deltoid on 14 May -Anthrax (5) and typhoid vaccines. She had received her 2nd Hepatitis B vaccine 2 days earlier, on 5/12/2009. She denies any significant or prolonged local site reactions. She reports some nausea, body aches and a headache within 24 hours of receipt of AVA and typhoid vaccines; these symptoms were mild and resolved within 48 hours. She also reports the onset of left-sided, constant sharp chest pain "right after" vaccine receipt. The pain continued through the week-end and was at its peak when it awakened her on the morning of 5/16/2009. She reports that her heart was beating fast, but denies shortness of breath, palpitations, or diaphoresis. There was no change in her chest pain with deep breaths or position changes. She sought evaluation at sick call on 18 May. Her evaluation included a normal exam, normal ECG and CXR. The diagnosis was "anterior wall chest pain with respiration" suspected to be musculoskeletal. She was started on Ibuprofen 800 mg TID and an ECHO was ordered. She followed up on 21 May with concerns of an allergic reaction to her vaccines with her chest pain almost resolved. (Since then she continues to report occasional episodes of sharp chest pain lasting seconds to minutes with no accompanying symptoms.) During her visit on 21 May, she was told that her tests to evaluate her chest pain were normal, and then additional labs (CBC, IGE, ESR and UA with HCG) were ordered. When the results of her UA demonstrated proteinuria, she was referred to Nephrology, with an initial visit on 28 May 2009. SM denied symptoms of hematuria, dysuria, urgency or hesitancy. She had no history of UTIs. Following review of patient records by Nephrology, previous episodes of proteinuria were noted in Jan 2005 (with negative repeat) and in Dec 2008. Additional labs were completed and the "watch and wait" approach was recommended. With follow-up in July 2009, her urine protein was within non-nephrotic range with normal renal function, she had intermittent pedal edema, she was normotensive and asymptomatic, and her labs to rule out possible etiologies of her proteinuria were negative. After significant increases in urine Protein/Creatinine and 24-hour urine protein were noted in Nov 2009, a renal biopsy was completed in December. At that time, patient was diagnosed with Chronic Focal Sclerosing Glomerulonephritis. With regular Nephrology follow up over the next year, SM was placed on high dose oral steroids, and a statin, calcium supplement, ACEI and ARB were initiated, with close monitoring of labs and blood pressure. After steroid taper was completed in Dec 2010, SM's Jan 2011 Nephrology note assessed "appears to currently be in partial remission with spot pr/cr <1". She will continue regularly scheduled labs and Nephrology follow-up every 3 months. SM recalls feeling well on day of and prior to vaccinations administered during May 2009. She denies allergic reactions to drugs, latex, and insect stings. She does not recall ever having any unusual or prolonged reactions at vaccination sites or systemic symptoms following receipt of other vaccinations.