Age: 34.0
Sex: M
Vaccine: SMALL
Symptoms: Anorexia, Arthralgia, Biopsy skin abnormal, Blister, Blood culture negative
Clinical narrative: On 6/16/2009 center was notified by hospital of a vaccine adverse event following involving this patient. The event occurred in May 2009. Review of related notes as well as phone interview indicated this 34 y/o male, developed fever, chills, malaise, loss of appetite, headache, sore throat, productive cough & mild shortness of breath onset approximately 10 days following receipt of small pox vaccine (SPV) given on 4/29/2009. This was the only vaccine received that day; however, on 4/23/2009 he received anthrax vaccine (AVA) dose #1, Hep B dose #1, influenza (IM), & typhoid vaccines. SM was initially seen in hospital 5/11/2009 for URI-type symptoms & gave history of prior intermittent chest congestion for 3 weeks; he was diagnosed with pharyngitis & prescribed Z-PACK, ZYRTEC & MUCINEX-D. That night he felt worse, spiked temperature, noted pain with swelling at SPV site left deltoid; he was taken to local civilian ER, diagnosed with left arm cellulitis & prescribed SEPTRA & Clindamycin. At medical center follow-up 5/12/2009 he had temp 101.7, small tender pustule in right axilla & right knee pain/swelling; he was placed on quarters & asked to continue antibiotic therapy. By 5/13, he felt worse & had developed scattered pustular lesions over scalp, right hip, left leg, & had increased right knee pain/swelling. On 5/13 he was admitted to hospital with presumptive diagnoses: right knee cellulitis & disseminated vaccinia. Initial assessment by Infectious Disease (ID) on 5/14 indicated overall clinical improvement, but continued right knee swelling/warmth without tenderness; blanchable red rash at SPV injection site (stable pustule), & over right knee; multiple scattered tense blisters, not excluding palms & soles: vesicles in various stages, characterized as yellow on erythematous base, umbilicated or ruptured, some becoming pustular, some with honey-colored crusts; distributed over scalp, neck, shoulders, axillae, upper extremities, trunk, buttocks, lower extremities. SM was diagnosed with 1) mild-moderate generalized vaccinia with clinical improvement although with new lesions within past 36 hrs; 2) hydrarthrosis right knee/tib/fib without overlying lesions secondary to reactive vs. possible septic joint, 3) leukopenia consistent with systemic viral infection - questionable prior episode with severe strep throat but no evidence of immune compromise, 4) normocytic anemia with low MCV/wide RDW suggestive of iron deficiency vs. hemolytic anemia related to vaccinia, 5) thrombocytopenia possibly related to vaccinia, unable to confirm if preexisting; splenic sequestration or ITP considered. Treatment with VIG considered if symptoms worsened. SM continued on IV Clindamycin with close monitoring. He continued to improve clinically & was discharged a couple of days later. On 5/27, at his first outpatient follow-up post hospitalization, he was well, back to baseline except for slight reduced exercise capacity. The SPV left deltoid was scabbed; all other skin lesions were resolved without scarring (except over right wrist biopsy site); right knee symptoms resolved; vaccinia felt to be clinically resolved, but concern for possible mild immunodeficiency state that predisposed him to vaccinia (old CBC from 10/2007 indicated similarly low values for WBC, Hgb/Hct, & Plt counts). SM was referred to Hematology at hospital on 6/12/2009. By then, CBC showed WBC 4.7, Hgb 12.8, Plt 89, MCV 89, normal diff; diagnosis was pancytopenia - resolved & probably due to viral illness. He was advised to have monthly CBCs until normal or Plt ct at least >100, Hgb >13; If CBC did not return to normal or worsened, he should be re-evaluated by hematology. SM was cleared to deploy.   7/2/09 Received medical records. FINAL DX: generalized vaccinia from vaccination; cellulitis of right knee; hydrarthrosis right knee; leukopenia; anemia; thrombocytopenia; elevated CRP & ESR Records reveal patient experienced fever, chills, night sweats, HA, skin lesions, fatigue, right knee pain & redness. ID & Derm consult done after malaise, HA, fever x 3 days followed by scattered superficial pustules.  Tx w/oral antibiotics w/minimal improvement.  Admitted ICU 5/13 for IV antibiotics.  Improved & d/c to home w/ID clinic f/u.  Mostly resolved by clinic visit of 5/27. w/continuing decreased exercise tolerance & easy bruising.  Referred to Heme.