Age: 5.0
Sex: M
Vaccine: PPV
Symptoms: Erythema, Full blood count normal, Incisional drainage, Injection site abscess, Injection site cellulitis
Clinical narrative: Information has been received in a published literature article, concerning a 5 year old male with suspected immunodeficiency, recurrent otitis media associated with hearing loss and speech delay, chronic rhinitis, chromosome 6q deletion (patent ductus arteriosus, facial dysmorphism, undescended testes), and a family history remarkable for asthma and environmental allergies, with no known immunodeficiencies or unexplained deaths. Skin-prick testing was negative to a panel of common aeroallergens. Screening immunology studies, including complete blood count with differential and quantitative immunoglobulins, were significant only for a slightly low absolute lymphocyte count (ALC) of 1500. On subsequent visits the ALC was followed and remained at this level. Four months later he continued to have recurrent otitis media and had begun to have recurrent sinus infections as well. Further investigation of his immune function was initiated, including titers to diphtheria, tetanus and pneumococcus, and a lymphocyte enumeration panel. His lymphocyte enumeration panel results revealed normal percentages and absolute numbers for CD3, CD4, CD8, CD16+56 and CD19 cells. In addition, he had protective titers to diphtheria and tetanus. However, he was found to have protective titers to only one out of seven pneumococcal serotypes tested. The patient was vaccinated with PNEUMOVAX 23 (dosage not stated) (date and lot # not reported) as part of an evaluation for possible immunodeficiency. He was instructed to have the titers repeated 3 weeks after the vaccination. "Approximately 24 hours after the PNEUMOVAX 23, he developed local and systemic reactions; he developed erythema, swelling and pain at the injection site on the right upper arm. Over the next 2 days, his erythema spread and he developed a temperature of 103 degrees F, diarrhea and vomiting. After evaluation in an emergency department, he was hospitalized for IV antibiotic therapy (unspecified) for cellulitis of his right arm. On admission, laboratory investigations revealed a white blood cell count (WBC) of 19.6 x10(3) cells/mm (3), with 89% neutrophils and an absolute lymphocyte count of 1600, an erythrocyte sedimentation rate (ESR) of 110 mm/h and a C-reactive protein level of 23.7mg/dL. The remaining complete blood count values were within their respective reference ranges. A peripheral blood culture was also collected prior to initiation of antibiotic therapy." "The erythema spread distally. When the erythema failed to improve, an ultrasound of the upper extremity was done that revealed no evidence of abscess. The patient received 5 days of antibiotic therapy, during which he remained febrile with minimal improvement in pain and erythema. The orthopedics team performed an incision and drainage of a right elbow abscess. Cultures collected ultimately grew coagulase-negative staphylococcus, which was thought to be a contaminant. After 5 days observation, his blood culture showed no growth." "After the incision and drainage, the patient showed rapid improvement; his fever resolved, and his pain and erythema decreased, with an increasing range of motion. He was discharged home with antibiotic therapy (unspecified). He subsequently made a full recovery and resumed full use of his right upper extremity." Approximately 2 months after the PNEUMOVAX 23 and hospitalization, the patient had protective titers to eight of the twelve pneumococcal serotypes tested. Additional information has been requested. A copy of the published article is attached as further documentation of the patient's experience.