Age: 47.0
Sex: F
Vaccine: SMALL, SMALL, SMALL
Symptoms: Lymphocyte count normal, Lymphocyte percentage, Malaise, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal
Clinical narrative: A patient received the vaccinia vaccine on July 23, 2012.  She complained of pain at the vaccine site on August 1, 2012 and was advised to use a warm or cold compress and to take over the counter pain medications (Tylenol, Motrin or equivalent).  Due to the pain at the vaccine site she was seen in MED DIV the same day.  On Exam there was a tense bulla surrounding the vaccine site which was opened and allowed to drain.  There were no evidence of secondary infection, no satellite lesions and no rash at that time.  The employee was seen again on August 2, 2012 and symptoms had improved.  She was seen again on August 3, 2012 when the vaccine site was noted to be improving, however the employee now reported having a headache and the vaccine site was noted to be accumulating fluid in a bulla.  HC was contacted and recommended symptomatic care.   She was seen again on August 6, 2012 and complained myalgias and 5/10 pain at the vaccine site and re-accumulation of fluid in the bulla around the vaccine site.  No fever, respiratory symptoms, gastrointestinal symptoms or urinary symptoms were noted at that time.  She was given two days off at that time and symptomatic care was continued.  She was seen again on August 9, 2012 with increased fluid accumulation in the bulla around the vaccine site, increased pain at the vaccine site and was noted to have erythema, warmth and tenderness around the vaccine site which was consistent with an early cellulitis/secondary infection.  This was treated with drainage of the bulla and Keflex with a planned 10 day course.  At that time she reported no systemic symptoms, no headache, no neck symptoms, no musculoskeletal symptoms, no neurological symptoms, and no psychological symptoms.    She was seen again on August 15, 2012 and reported feeling better and was noted to have improvement in the appearance of the vaccine site with decreased pain, no redness and a well formed scab that was about to fall off.  At that time she reported mild fatigue and mild myalgias.  On August 16, 2012 she returned for evaluation reporting a pruritic rash (macular semi confluent erythema with no vesicles) on the anterior central upper chest that had started the same morning.  The rash did not appear to be consistent with the typical rash associated with vaccine vaccination at that time.  The vaccine site was tender but not warm.  The scab at the vaccine site was dry and lifting at the edges.  There were multiple patches of resolving erythema on the skin surrounding the vaccine site where tape and been applied and removed.  At this time she was planning to leave for a vacation the next day.  The rash was felt to be mild and possibly secondary to the vaccine, the antibiotic, or a combination of increased sensitivity due to the vaccine and the antibiotic.  Due to the mild nature of the symptoms it was felt to be safe for her to continue the antibiotic and to take her vacation.  She was advised to stop the antibiotic and seek medical care if her symptoms worsened.  On August 17, 2012 while in Florida her symptoms worsened when she took the antibiotic.  She attempted to contact the occupational health provider she had seen the previous day (apparently she did not attempt to contact the on call provider through the security desk) but did not make contact (she left a voice message describing her symptoms).  The occupational health provider was unable to reach her by phone when he received the voice message but sent her a text message instructing her to stop the Keflex, seek medical care if symptoms continue, and to take an antihistamine for itching.  That evening she sought medical care as instructed the previous day when seen by providers.   On evaluation in the medical facility her symptoms were thought to be due to the vaccinia vaccine possibly confounded by the antibiotic.  She was instructed to stop the antibiotic and was treated with steroids (oral prednisone) and an antihistamine (hydroxyzine).  She initially improved, however, symptoms worsened when she started tapering the steroids as instructed by the medical facility.  On August 27, 2012 she was seen by providers in MED DIV for evaluation of the worsening rash.  She reported that when she started to decrease the prednisone the rash and symptoms started to get worse. Prominent symptoms were myalgias, pain/throbbing at the vaccine site and a worsening fine popular, blanching rash on the anterior chest and arms.  On exam the vaccine site scab noted the previous week had fallen off leaving a rough, scared circle with no drainage.  The area around the vaccine site was tender with no mass or fluid collection noted.  There was no redness or warmth.  Hyper-pigmented patches where tape has previously been applies were present. No axillary lymphadenopathy or tenderness was noted.  Her systemic symptoms were thought to be secondary to the vaccinia vaccine possibly complicated by a drug reaction contributing to the rash.  She was advised to continue the steroids and antihistamine and discontinue HCTZ.  She was advised to monitor her blood pressure and contact her personal doctor to discuss either stopping the HCTZ until her symptoms resolved or substituting a different blood pressure medication.