Age: 88.0
Sex: F
Vaccine: PPV
Symptoms: Laboratory test abnormal, Lethargy, Rash, Urticaria
Clinical narrative: Information has been received from a medical assistant concerning an 88 year old female pt non-smoker with no known drug allergies, no history of other drug use, dementia, depression, and past medical history arthritis and cystitis, who on 9/24/02 at 13:30 was vaccinated by IM injection in the left arm with a first dose of pneumococcal vaccine 23 polyvalent (642719/0376M) and developed SOB, welts, redness, and pain around the injection site. It was reported the events continued for "five days" after the pt was vaccinated with pneumococcal vaccine 23 polyvalent. No intervention data was provided. Follow-up info received from physician included medical records. On 9/25/02 the pt who resides in a nursing facility presented to the ER via transport by ambulance with symptoms described by the nursing home staff as "decreased activity and increasing weakness, lethargy." The emergency physician reported the pt had been seen by a physician on 9/24/02 and received, "some type of immunization shot, which was believed to be a pneumonia shot in her left arm yesterday." It was noted the pt has had a rash over the left shoulder and arm area, which had not been mentioned. It was noted the son indicated the pt did not seem much different than usual, but he felt the evaluation in the ER was appropriate. It was reported the pt had not had any vomiting, no specific fevers, no other skin rash had been noted, and she had no weakness or numbness of her arms or legs. The emergency physician noted that further history was "somewhat difficult" to obtain secondary to her underlying dementia. On examination the pt was sitting upright in bed, was somewhat awake and alert, and appeared somewhat confused at times. It was noted she was not in any respiratory distress, and did not appear to be lethargic. On examination her temp was 98.5, blood pressure 125/62, pulse 73, and respirations 20; her HEENT exam showed pupils were equal, round and reactive to light, extraocular movements were intact, sclerae were anicteric, oropharynx was pink without erythema or exudate, mucous membranes were slightly dry, her neck was supple, no jugular venous distension; Heart examination revealed regular heart sounds S1 and S2, there were no murmurs, rubs or gallops; Lungs were clear to auscultation bilaterally; Abdomen was soft, nontender, and nondistended; extremities revealed no lower extremity edema or calf or thigh tenderness. It was noted the pt had a "significant amount" of erythema and "slight" induration in the left upper extremity over the entire anterolateral and posterior shoulder area as well as the proximal upper arm, which appeared to be somewhat tender to the pt. It was noted there was no fluctuance or areas of abcess, no axillary adenopathy, and no other obvious skin lesions. The skin was noted as warm and dry, no petechiae or purpura. Neurologically the pt was reported awake, and alert with no focal motor or sensory changes to light touch. It was noted again the pt did appear "somewhat confused at times." Concomitant medications included Aricept, hydrochlorothiazide/triameterene, estrogens, Premarin, Risperdal, Zoloft, Tylenol and a multivitamin. The following diagnostic studies were completed: white blood cell count 12.1, hemoglobin 12.1, hematocrit 36.4, glucose 111, electrolytes, blood urea nitrogen and creatinine were all "normal," urinalysis normal, and chest x-ray showed no evidence of infiltrate or effusion and no pneumothorax. A urine culture and blood culture were obtained and results were pending. The emergency room physician reported that in light of hte pt's history and findings, her symptoms did not have a specific etiology. The physician noted that the pt did not appear at that time, as significantly lethargic, and with the history from the pt's son that corroborated the lethargy assessment, the physician felt that the evaluation for what appeared to be a left upper extremity cellulitis would be appropriate. It was again noted the pt had a recent hisotry of an "immunization shot" and it was felt that a possible reaction from the immunization, which included a histamine-type reaction should be considered, but also the pt's symptomalogy indicated the possibility of cellulitis. It was noted an IV was placed and the pt was treated with 1gm of cefazolin IV. It was noted ER physician spoke to the physician who had administered th edose pneumococcal vaccine 23 polyvalent and it was felt appropriately to continue the pt on cephalexin. The physician noted the pt did not have any specific criteria for admission, and she appeared fairly coherent, so it was felt the pt could safely return to the nursing home facility for close observation. It was noted that on 9/26/02, she would see the physician who had administered pneumococcal vaccine 23 polyvalent for a re-check. It was noted the pt would return should the pain, swelling in the left arm worsen, if there were fevers or change in her mental status or any other problems. The following diagnoses were reported, generalized weakness of uncertain cause, cellulitis left upper extremity, and possible infection related to recent pneumococcal vaccine shot in the left arm. The pt returned to the nursing facility where she resides in stable condition. It was noted the pt recovered. Additional info has been requested. The reporter mentioned that another patients also had an experience following vaccination with pneumococcal vaccine 23 polyvalent (WAES0209USA02696).