Age: 14.0
Sex: F
Vaccine: HPV4, HPV9
Symptoms: Epistaxis, Eye irritation, Face oedema, Fatigue, Feeling cold
Clinical narrative: Mast Cell Activation Syndrome; This literature marketed information has been received from the authors in a published article title as stated below and refers to a 15-year-old female patient. The patient had Eczema and allergies by age of 3-years-old. At 10 years-old, a barky dry cough persisted for a year. When she was 12 years old, diagnosed with asthma and started having frequent episodes of bronchitis. Subcutaneous immunotherapy was attempted but only seemed to cause worsening reactions over time, eventually recurrent anaphylaxis. Chronic fatigue emerged too. Family history was notable for healthy parents, a sister with allergies, another sister with high histamine-content food sensitivities and vigorous reactions to bee stings, a paternal grandfather who had had fatal colon cancer in his 70s, a paternal grandmother who had had fatal heart failure, a maternal grandfather who had had fatal esophageal cancer at 85 (but who had not been a smoker or heavy drinker), a maternal grandmother who had had fatal ovarian cancer at 73, and a maternal aunt who had had breast cancer in her early 60s and after that developed "a lot of funny skin reactions". The patient denied any history of smoking, significant alcohol use, or illegal substance use.   On an unspecified date, At age of 14-years-old, she received her first dose of unidentified Merck hpv vaccine administered, also reported as Gardasil (Lot #, expiration date, dose, route of administration and anatomical location of vaccine were not reported) for prophylaxis vaccination, "and that is when the floor just dropped out" with marked worsening of fatigue (often could not finish the schoolday), idiopathic anaphylactoid reactions every day, recurring idiopathic fevers despite extensive evaluation, reacting to foods but testing negative for allergies to these foods, reacting to chemical odors/fragrances, chronic nausea, post-prandial reflux and vomiting, diarrhea alternating with constipation, hair falling out in clumps (diagnosed as alopecia areata), and frequent palpitations as well as severe presyncope (once occasioning hospitalization for a heart rate of 180 (unspecified units)). She also developed frequent "bone pains" in her legs (osteomyelitis disproven). Other symptoms which emerged included flushing, feeling cold much of the time, headaches, diffusely migratory aching/pain, diffusely migratory pruritus, unprovoked soaking sweats (usually at night), unprovoked fluctuations in weight and appetite, irritation of the eyes, vision disturbances, epistaxis, easy bruising, sinonasal congestion, coryza, post-nasal drip, possible intranasal sores, frequent pharyngeal thrush and occasional throat sores, dyspnea, gastroesophageal reflux, nausea, vomiting, diarrhea alternating with constipation, diffusely migratory abdominal discomfort including (usually post-prandial) bloating, diffusely migratory weakness, diffusely migratory edema (mostly about the face), diffusely migratory bilateral cervical adenitis, orthostatic and non-orthostatic presyncope, cognitive dysfunction (particularly memory, concentration, and word-finding), hair loss, unusual deterioration of dentition despite decent attention to dental hygiene, diffusely migratory rashes (typically patchy macular erythema), hives, eczema, hypersomnolence, sleep paralysis, and poor healing in general. Upper gastro-intestinal (GI) tract endoscopy was unrevealing, but she reacted to propofol and self-explanted her IV several times during the procedure. She was having frequent "bone pains" in her legs, once thought to be osteomyelitis, but this was disproven. At 15-years old, she engaged a new pediatrician, who was the first to suggest that a mast cell activation syndrome might be the root issue. Diagnostic testing was strongly positive. Her diet had been reduced to only three tolerable foods, but she then consulted an immunologist and was started on oral Cromoglicic acid (CROMOLYN), famotidine, levocetirizine, and fexofenadine, whereupon she was able to significantly expand her diet. She soon consulted with an MCAS expert, who confirmed the diagnosis and recommended an increase in Cromoglicic acid (CROMOLYN) and initiation of aspirin and omalizumab. She improved on aspirin, but omalizumab immediately worsened her fatigue and allergic reactions. Omalizumab was stopped after the second monthly treatment, and she improved. Physical examination at the time of her initial evaluation found a vaguely wan/fatigued appearing, trim young woman in no acute distress other than intermittently exhibiting modest headache behaviors, pleasant, cooperative, fully alert and oriented, easily independently ambulatory, presenting with her obviously appropriately concerned/supportive mother. Vital signs were notable for a pulse of 103. Key findings were her vaguely constitutionally unwell general appearance, HEENT benign, no plethora/pallor/diaphoresis/jaundice/rash/bleeding/bruising, diffusely mild dryness all about her skin, neck supple, no JVD or thyromegaly or carotid bruits, no palpable adenopathy or tenderness at any of the usual node-bearing sites, clear lungs, regular heart with no adventitious sounds, abdomen completely benign, zero peripheral edema, neuro grossly intact. No costovertebral angle or spinal column tenderness was evoked on palpation and percussion about these areas. On a light scratch test on the upper back, mildly bright dermatographism (erythroderma only, no hives) quickly emerged and was fully sustained when last checked 10 minutes later  Literature report:  Upon internal review the of Mast Cell Activation Syndrome (MCAs) was considered as medically significant.   This is one of several report from the same literature article.   A copy of the published article is attached as further documentation of the patient's experience.