Age: 26.0
Sex: F
Vaccine: FLU3, PPV
Symptoms: Joint stiffness, Laboratory test normal, Lymphocyte percentage, Maternal exposure during pregnancy, Metabolic function test normal
Clinical narrative: AD patient received annual AFLURIA (CSL lot #UT424AA) and PNEUMOCOCCAL vaccine (lot # 1397Z) on 12/5/2011 in the upper left deltoid. At 3 hours later she c/o 3 red slightly raised nonpruritic area's to mid left lateral upper arm with 5/10 pain which worsened if moved. "Felts as if someone threw something at me or punched me". She denied any trauma, fall, injury, or moving of large items. Later that evening a pinpoint red dot appeared in center of highest red patch with streaking connecting two red patches. Her pain increased to 10/10 and was described as a constant throb. On 12/6-7/2011 (24-48 hours later) she c/o fever 102.6F, nausea, vomiting, left axillary tenderness with increased redness and swelling to lower portion of left upper arm. TYLENOL every 6 hours eased the pain and fevers. Her medical records note afebrile unremarkable exam by cardiology 12/7/2011 for palpitations and lightheadedness (worse since pregnant). She was diagnosed with sinus rhythm/tachycardia via lifeline holter monitor and restarted in INDERAL. On 12/8/2011 (72 hours) she was evaluated by clinic for possible insect bite (she noticed mosquitoes in her home within 24 hours of onset of symptoms) and pain to left arm and fever. Her temperature was 98.5F with heart rate 109. She reported a 3 day history of redness and pain to upper left arm as minor soreness that radiated down to elbow with stiffness and pain, intermittent fevers that respond to TYLENOL and MOTRIN, and nausea, vomiting and abdominal crampy pains. She complained of pain with extension of left arm as if a "rubber band is going to snap:. She was referred to nearby ER with diagnosis of possible tetanus/spider bite for labs and IV antibiotics - her temp was 98.9F, heart rate 105 to 72 bpm (after given IVF bolus). labs showed D-dimer 0.92 (0.1.19), CBC normal with RBC 3.74 (3.8-5.20), HBG 11.3 (11.7-15.5), and HCT , WBC and lymphocytes 20%. BMP an UA were normal. PVL study of LUE (internal jugular, subclavian, axillary and brachial vein) was negative. IV right hand was removed due to complaints of pain from IV site resulting in oral administration of KEFLEX instead of IV. Both providers' documented 3 x 5 patch of mild erythema and warmth over mid left humeral area dorsal aspect without rash or lymphangitis that was painful to light touch. She resisted flexion-extension of her left elbow or lifting shoulder due to pain, but later was able to extend and flex. Radial pulses were strong equal bilaterally with normal sensation, no bruising or blistering. She was released with contusion instructions and diagnosis of arm pain, dysuria and fever. Follow up with her PCP on 12/9/11 resulted in a second referral to ER for evaluation by infectious disease who gave a diagnosis of cellulitis, pregnancy and pain. She was treated with PERCOCET, prednisone, ZYRTEC and ZANTAC (already on KEFLEX). On 12/14/2011 she advised the redness/swelling were resolving, however her left arm pain persisted and she was referred to clinic by infectious disease provider for further guidance. On 12/19/2011 (day 14-16 after vaccination) continued left arm redness, pain and intermittent tingling down to fingers (following radial nerve from elbow across anterior arm to pain and thumb). Exam - 2 resolving left mid humeral red/brown discoloration s (now 1x1 cm and 1.5x 2 cm) to skin about 4 inches from shoulder and 3 inches below vaccine injection sites. Exam on 12/21/2011: resolution of redness and swelling to left arm (LA circumference was 12 inches on 12/15/11, 11.25 inches on 12/19/2011 and 10.5 inches on 12/21/2011. Skin temperature normal with mild hypersensitivity to touch. She could move her left arm but complained of discomfort to lower bicep/elbow with full extension/flexion and occasional tingling jolt to palm/thumb. Left shoulder exam unremarkable. Speeds and Yergason tests were positive with worst pain along lower anterior bicep region.