Age: 39.0
Sex: M
Vaccine: PPV
Symptoms: Ankle fracture, Arthritis, Chest discomfort, Depression, Erythema
Clinical narrative: Information was received regarding a case in litigation concerning a 39 year old male. Information received from the patient and medical records. The patient claims that on 20-DEC-2012, he was vaccinated with PNEUMOVAX 23 and experienced an allergic reaction. The patient stated that the effects of the allergic reaction severely discolored his face. As a result of the patient's allergic reaction, the patient reported "ongoing fear of public exposure, depression and mental stress." Information received from medical records concerning a 39 year old male (210 pounds, 71 inches) with penicillin allergy and history of asthma as a child. On 20-DEC-2012, the patient was vaccinated with PNEUMOVAX 23 (Lot number H014283, expiration date 17-APR-2014) via right deltoid. On 20-DEC-2012 at 1130 (approximately one hour after the vaccination), the patient was brought to the clinic with complaints of "upper body feeling itchy, feel a buzz in face and face feels red and hot." On examination the patient was noted to have some facial flushing, no shortness of breath noted and no rashes noted on his body. The physician noted that according to nursing assessment, the patient complained of tightness and itching on the chest as well. The physician reported the patient remained alert and oriented and appropriate vital signs were obtained. The patient was monitored for signs and symptoms of allergic reaction and also educated to report symptoms and return if needed. On 27-DEC-2012 examination, the patient felt improved and denied any shortness of breath, or feeling of flushing in his face. The physician explained to the patient that he may have had an allergic reaction. On examination, the physician reported the patient's skin showed no rashes or urticarial type lesions. The physician stated the patient with history of allergic reaction possible to PNEUMOVAX 23 on 20-DEC-2012 when he was given ZANTAC and hydroxyzine twice a day for the next five days. The physician reported this issue has been resolved. Information was received from medical records on 04-FEB-2016 regarding a 39 year old male with penicillin allergy and history of asthma as a child. On 20-DEC-2012, the patient was vaccinated with PNEUMOVAX 23. On 20-DEC-2012 it was recommended the patient return in one week regarding follow up for questionable reaction to PNEUMOVAX 23, medications included ZANTAC and ATARAX. On 28-MAY-2013, follow up visit the patient complained of dark skin on face from previous allergic reaction to PNEUMOVAX 23. On examination the physician reported that patient presented with dark patches in front and cheek areas, no inflammation or discharge. The patient had requested dermatology evaluation and it was noted medically unnecessary. The physician assessment: hyperpigmentation accentuated in sun exposed areas, and hydrocortisone (HC) 1% cream was ordered. The physician noted seizure disorder clinically stable and patient to continue DILANTIN. On 17-MAR-2014, the patient requested a dermatologist consultation for evaluation and treatment for his dark spots on his hand and face. It was noted the patient has a history of seizure disorder (2013), right first metacarpal arthritis, right thumb with old fracture, left ankle old united fracture of fragments, facial hyperpigmentation, probably solar induced. The physician on examination noted the patient with hyperpigmented spots and patches of facial areas, mostly solar induced as discussed in the past. The physician noted old orthopedic problems also right elbow tendonitis and ankle sprain. The physician reported dermatology evaluation not medical necessary, the patient to continue current treatment for seizure disorder, pain with TYLENOL and return to the clinic if not significantly better. On 26-FEB-2015 the physician reported the patient with the following chronic problems: human immunodeficiency virus positive (HIV) and seizure disorder. All available medical records will be provided upon request. Additional information has been requested.