Age: 70.0
Sex: M
Vaccine: HEP, YF, HEP, TYP, YF, HEP, YF
Symptoms: Gastric haemorrhage, Gastritis, Hepatic enzyme abnormal, Hepatic failure, Hepatic necrosis
Clinical narrative: Information has been received from a health authority concerning a 70 year old overweight male with hypertension, headaches, and insomnia, and no known immunodeficiency disease or steroid use, who on 4/10/03 was vaccinated with a dose of hepatitis B virus vaccine. On 4/10/03 the patient was also vaccinated with a dose of typhoid vaccine and a dose of yellow fever virus vaccine live. On 4/2/03 the patient was vaccinated with a dose if hepatitis A vaccine (inactive). It was unknown if there were any concomitant medications. On 4/14/03 the patient complained of not feeling well. On 4/16/03 the patient called the vaccination clinic to report aching in his hips, back, neck and all over. Later his family doctor documented a temperature up to 103 degrees. The data of this doctor visit was unknown at this time. On 4/17/03 the patient was hospitalized. On 4/18/03, the next day, the patient expired at the hospital. Lab results showed an AST greater than 6000, an ALT greater than 2000 and platelets of 5200. Upon autopsy, a necrotic liver was revealed, as well as a picture of DIC. No blood was available but fixed tissue was sent for follow up testing. No further information is available. A 15-day follow report received on 7/3/2003 adds: On 06/12/2003, additional info was received from the Centers for Disease Control and Prevention through e-mail correspondence that reported that the pathologist stated that the pt tested positive for yellow fever antigens. Multiple organs were positive for yellow fever on immunohistochemical examination, including the liver, lung, spleen, kidney, heart and pancreas. No other info was reported. No further info is available. The follow up received on 6/18/03, it wsa reported that the pt was vaccinated with hep B virus vaccine (Engerix B) (5305A6) on 4/10/03 and hep A vaccine (Havrix) (73784) on 4/2/03. The hospital hisotry and physical report was provided and indicated that the pt complained of weakness and shortness of breath and had not been feeling well for a few days. He was transported to the hospital by EMS with a blood pressure of 90/46 and a heart rate of 108. Within the ER, the pt was noted to be quite dry and had blood pressure as low as 60 systolic. He was also noted to be tachycardic. The pt was noted to have an abrasion involving the right pretibia. Blood and urine cultures were obtained, and the pt ahd a central line placed in his right femoral vein due to difficult access in the prominal venous circulation. While awaiting transfer to the critical care unit, he became increasingly more hypoxic and moribund. Intubation was immediately performed and a large mucous plug was extracted. The pt was maintained in the intubated state and transferred to the critical care unit. During the physical examination, his blood pressure was 102/59 with a pulse of 130 and regular, temperature of 100.4, respiratory rate of 27. Admission liver enzymes were elevated: SGPT 2042, SGOT 4137, platelet count 69,000, BUN 66, creatinine 4.9, potassium 4, CO2 12, alakaline phosphatase 179, bilirubin 3.2, albumin 2.8, glucose 91, calcium 8.5, troponin 0.23, lactate 9.5, WBC 7,000 with 21 bands and neutrophilic vacuolization was present, dohle bodies were noted on manual differential, HgB 15.5, INR 1.4, PTT 40, d-dimer was positive at 9381. EKG revealed sinus tachycardia with some diffuse nonspecific T-wave findings. Blood cultures had no growth. Blood gases included a pH of 7.09, PC02 45, PO2 67, calculated bicarbonate 13.3. On 4/18/03 the lab findings were BUN 75, total bilirubin 3.6, AST 6247, ALT 2850, albumin 1.9, globulin 2.5, BMP 793, creatinine 5.6, SGPT 2850, SGOT 6247. The pt's temperature was recorded as 103.5 F. A chest x-ray showed diffuse patchy infiltrates at the perihilar area. The hospital admission assessment was as follows: 1. Early sepsis with DIC possibly seconary to either a pulmonary, gastrointestinal or genitourinary source. The role of Malarone is unclear but probably not associated with an acutely decompensating state. Rule out ischemic bowel. 2. DIC secondary to #1. 3. Elevated liver chemistries probably related. Passive congestion also an issue. 4. Lactic acidosis related to #1. 5. Hisotyr of hypertension, benigh prostatic hypertrohy, hyperlipidemia and gastroesophageal reflux disease, all apparently stable. There has been a remote history of gastrointestinal bleed. 6. Acute renal failure consistent with ATN. The pt was treated with Zosyn, gentamycin, Zithromax, IV fluids and dopamine for blood pressure control. Pepcid wasa also given. Despite supportive therapy, the pt's overall condition deteriorated and he expired at 15:10 on 4/18/03. An autopsy was performed on 4/19/03 at 12:10.  Follow up on 07/07/2003: "The immediate cause of death is cardiopulmonary arrest secondary to multiorgan failure, most likely due to sepsis.  The manner of death is natural." The follow up received on 7/14/03 states, it was reported that the pt was taking additional medications at the time of hospital admission. Per the hospital admission record, a copy of which is on file at manufacturer, it is noted that the pt had been prescribed Sonata 5mg, as needed while traveling, Valium 10mg, as needed for travel anxiety, Diamox 500mg, as directed for mountain sickness while travelling, Cipro 500mg for traveling an dmalarone for malarial prophylaxis. No additional info was provided at this time. Case is closed.