Age: 20.0
Sex: F
Vaccine: PPV
Symptoms: Back pain, Chills, Headache, Injection site reaction, Musculoskeletal stiffness
Clinical narrative: The patient was last seen on August 11, 2008.  Interval history reveals that the patient received PNEUMOVAX on August 28th because she had low pneumococcal antibody titers on laboratory evaluation performed on August 20th.  She had 1 of 14 serotypes protective.  The rest of her immunologic evaluation was basically within normal limits.  The patient had been complaining of recurrent upper respiratory tract infections and to complete her immunologic evaluation she received PNEUMOVAX vaccination on August 28th.  To be brief, the patient had a prolonged febrile illness characterized by headache, neck stiffness, back pain, nausea, emesis, and large local reaction at the vaccination site beginning one day following her PNEUMOVAX vaccination.  She was admitted to the hospital on August 31st where she had a thorough evaluation for this illness including lumbar puncture and blood cultures as well as urine culture.  She was found to have evidence of possible urinary tract infection and was placed on Rocephin.  She was also started on a course of Solu-Medrol.  Her blood cultures and lumbar puncture were negative.  The patient did well and was discharged on a course of oral steroids as well as Cefzil.  She did well until she discontinued her oral steroid dose on September 5th.  The following day while she was still on Cefzil she spiked a fever to 101.6, had chills, nausea and headache without emesis.  These symptoms persisted and on the next day she was seen by a college physician.  CBC was drawn and WBC was said to be elevated at 16,400.  She was referred to a local internist who restarted Cefzil 250mg b.i.d. for a five day course.  The patient continued to have similar symptoms until September 11th when her symptoms resolved.  Currently the patient is relatively asymptomatic with the exception of intermittent episodes of mild generalized headache and nausea.  The patient's reactions as noted above including extremely large local reaction at the PNEUMOVAX vaccination site as well as her systemic illness is probably an adverse reaction to her PNEUMOVAX vaccination.  After review of the literature, this reaction is exceedingly rare.  In a normal patient there has been only one other case report that I could find of this type of reaction.  The immunologic mechanism of this reaction is not clear to me because of the time course.  This does not appear serum sickness reaction.  This patient's reaction lasted for approximately 13 days.  The longest other reaction that I could find in the literature lasted for nine days.  As stated above, this is an extremely rare reaction.  It appears as if the reaction was improved with the use of steroids rather than antibiotics.  I will be reporting this reaction to the FDA.  The patient is to follow-up with me in December when she returns home from school.  She was cautioned never to have PNEUMOVAX again in the future.  We will be repeating the CBC along with post PNEUMOVAX vaccination titers in two weeks.  11/21/08 Reviewed medical records from reporter of 8/28/08-9/15/08.  Also included hospital medical records. FINAL DX: probable AE reaction to pneumococcal vaccination; vasomotoe rhinitis; history of recurrent upper respiratory tract infections of unknown etiology. Records reveal patient RTC on 9/3.  Had phone call 8/30 w/fever, HA, stiff neck, back pain, aches, N/V, left arm pain, redness & pain.  Sent to ER & was admitted for IV antibiotics.  D/C to home on oral antibiotics & steroids.  When finished steroids on 9/5, spiked fever again w/chills, nausea, HA.  Seen in college health center, WBC 16,400 & referred to local internist who restarted antibiotics.  Continued to have symptoms until 9/11/08 when symptoms resolved.  Having intermittent episodes of mild generalized HA & nausea when seen 9/15.  Reviewed hospital medical records of 8/31-9/03/2008. FINAL DX: UTI; pneumovax allergic reaction; s/p LP HA, resolved. Records reveal patient experienced fever of 103 w/LUE swelling, redness, pain & decreased ROM, nausea, vomiting, back pain, urinary frequency.  Seen in ER & d/c to home.  Returned to ER when symptoms continued & worsened.  Progressed well & d/c to home on continued oral antibiotics & steroids. Tx w/IVF, antibiotics.  ID consult done.