Age: 65.0
Sex: F
Vaccine: PPV
Symptoms: Arthralgia, Borrelia test negative, Bursitis, Fluid retention, Full blood count normal
Clinical narrative: Information has been received from a physician concerning a 65 year old female patient with no known drug allergies/reactions and no pertinent medical history who on 01-DEC-2009 was vaccinated with her first dose of PNEUMOVAX 23 (Lot # 664864/1365Y) in her left deltoid. There was no concomitant medication. It was reported that the patient experienced pain and swelling in her joints all over her body. The symptoms started as left shoulder pain and swelling but seemed to have settled in her right knee. The patient was seen in the office several times for the pain but nothing abnormal was seen upon exam. The only diagnostic tests were blood tests: erythrocyte sedimentation rate, complete blood cell count and "lyme" that were normal. At the time of the report the patient had not recovered. Follow up information has been received from the physician who reported that the patient stated that she continued with pain. It was also reported that the physical exams had all been normal and lab tests were normal too. It was mentioned that the "patient had other problems but not from the PNEUMOVAX 23". Follow up information has been received from a physician via medical records, concerning a 65 year old female patient with oesophageal acid reflux and hypertension who on 01-DEC-2009 received her first dose of PNEUMOVAX 23 at 9:00 am. Concomitant therapy included pantoprazole, Lactobacillus acidophilus and bisoprolol fumarate/HCTZ. On 02-DEC-2009 at 8:05 am the patient's left arm was swollen and painful at the injection site. The patient was told to use MOTRIN and ice. At 14:00 pm on the same day the opposite arm also swollen but without pain, the physician advised to use ice and ADVIL or TYLENOL. On 04-DEC-2009, the patient complaint of both arms swollen and painful, her right knee was also swollen and painful, she was not able to walk properly, and it even hurt if she touched the area. The patient states that both her arms are swollen and painful, as well as her knee. The physician ordered BENADRYL 25 mg every 6 hours as needed with ADVIL. 07-DEC-2009, the patient complained of both arms swollen, her right knee pain. Patient stated not able to walk properly and it hurt even is she touched the area. On physical exam, was no acute distress. She had significant tenderness on palpation of the injection site. She does have some swelling in her legs. The physician was not 100% convinced this is from the PNEUMOVAX 23, so she was sent for a full rheumatologic workup, including CBC, ANA, rheumatoid factor, sed. Rate and a Lyme titer. Depending on the findings, she will be followed accordingly and MEDROL DOSE PACK was given. On 09-DEC-2009, the patient still had pain on the left arm and shoulder, her right knee, the patient finished MEDROL DOSE PACK and was using ibuprofen as needed, basis, 200 to 400 mg every 6 hours. Her labs showed sedimentation rate was 33, ESE was normal. She had a Lyme titer which was normal. Clinically she did feel improved. She had no fevers or chills. Initially she said she was unable to lift her left arm. Now she is back to normal range of motion. On exam, she looked well. She had some mild tenderness over the lateral aspect of the left shoulder but normal range of motion. She had no obvious effusion of the knee. She did appear to have excessive adipose tissue below the right knee. The physician did not detect any edema or bursitis of her lower extremity. It was concluded that she had an exaggerated reaction to the PNEUMOVAX 23, possibly serum sickness, but she was clinically improving. She asked me about a ZOSTAVAX (Merck) (MSD), but based on the response to the PNEUMOVAX 23, the physician certainly did not recommend the ZOSTAVAX (Merck) at this time. Patient to continue with MEDROL DOSE PACK taper dose as directed. On 16-DEC-2009, patient called complained of arms and knee still swollen, still not walking. On 22-DEC-2009 her left shoulder and arm pain resolved, her knee was still on pain. The patient said she can't walk. Physician reported that she did ambulate into the office. She said she is retaining water in her arms. Her right knee was swollen. She stated multiple times that her physicians "screwed her up". She did have labs drawn which were essentially normal except for a sedimentation rate which was mildly elevated when she initially came to the doctor's office. She was also treated with MEDROL DOSE PACK which at the time did seem to help her symptoms slightly. She stated that she refused to go to the hospital or through the ER for further testing. On physical examination, she was afebrile, in no acute distress. Examination of the extremities showed no obvious edema. The knees did have significant adipose tissue, however in comparison to the right left knee, they looked very similar. No tenderness to palpation. She had full range of motion. Pulses are 2+. It was reported by the treating physician that there was nothing more at this point that she was clinically improving. She needed to continue to wait this out. He did agree that there was nothing on physical exam that showed any abnormalities. Patient referred for aqua therapy upon patient's request. On 23-FEB-2010, patient still has swelling and pain in the right knee but was feeling great for past two weeks because she was traveling and had no pain or swelling at that time. She is "back" and had increased knee pain. On 10-MAR-2010, the patient saw an orthopedic doctor, and she was diagnosed with osteoarthritis of the knee. 15-MAR-2010 the patient went to an office visit with her husband, she had a walker with a seat, and she said she cannot really ambulate without that. She saw the orthopedic surgeon. She complained of swelling in her arms and in her right upper leg. However, she had no swelling of her hands or her feet. She had a general puffiness but her physician did not see appreciable swelling. The orthopedic surgeon said she had a bursitis. He gave her an injection in her knee, which gave her some relief but it was only temporizing. She is not taking anything orally. The patient was going to vacation in about two weeks. The physician suggested a rheumatology evaluation. She did take a course of steroids it made her fell wired and gave her a day's relief. On 24-MAR-2010, the patient was seen at an arthritis and osteo-center, she had no swollen joints or edema in upper extremities. The patient did have an injection prior to a vacation. The patient did have PES anserine injection at her last visit. The patient stated that she was pain-free for approximately a week's time. The patient did not notice any change in her walking. She was still ambulating and still having to use a wheeled walker. On the physical examination, the patient had some mild tenderness over the PES anserine bursa and mild tenderness over the medial and lateral joint lines. The patient had crepitus with range of motion from 5 degrees to approximately 115 degrees. Apley's compression was negative. Quadriceps and hamstrings strength were 5/5 but did give her crepitus sensation when performing maneuvers of quadriceps resistance. Calf was without any pain or cord. Distal sensation was intact. The physician concluded that the patient's PES anserine bursitis was resolving and she had moderate osteoarthritis changes of the medial and lateral joint and moderate to severe changes at the patello-femoral joint. The right knee joint was then injected with 2 ml of KENALOG and 3 ml of lidocaine. The patient tolerated the procedure well. The patient was given post injection icing instructions over the next two days. She was told to rest during this time. The patient continued about her daily activities and continued on her trip doing as she tolerated. The patient has rented a scooter while on her cruise ship in case she had any problems with ambulation. The final impression of the physician was osteoarthritis, anserine bursitis, peripheral edema and subjective forearm swelling after pneumonia vaccine. The patient was recommend to being treated by Orthopaedics for her osteoarthritis and her anserine bursitis and they have improved with corticosteroid injection. She was not having any pain and has normal functioning of the upper extremities. She did have some lower extremity edema and management of this was deferred to Primary Care. She did have a slightly elevated ESR, but she is adamant against having repeat ESR done or any other lab workup. She will return to Primary Care for follow up, in addition to her orthopedist. On 23-APR-2010, the patient went to the physician for a follow up evaluation of her right knee pain. The patient did well during her vacation and was experiencing some crepitus but no pain in her knee. She had no particular discomfort over the PES anserine bursa. No particular discomfort over the medial or lateral joint line. The patient did have crepitus with range of motion from 5 degrees to approximately 115 degrees. Quadriceps and hamstrings strength were 5/5. Calf is without any pain or cord. Distal sensation was intact. The patient will continue with her daily activities. The physician recommended her to straight leg raises to help keep her strength up around the knee. At the time of the report the patient had not recovered from peripheral edema, anserine bursitis and osteoarthritis. Upon internal review unable to walk and the use of walker was considered to be disabling. Additional information has been requested. All available medical records will be provided upon request.