Age: 33.0
Sex: F
Vaccine: TYP, YF
Symptoms: Erythema, Fatigue, Injection site inflammation, Injection site pruritus, Injection site rash
Clinical narrative: Patient contacted office concerned about dime size red raised ball like reaction that was warm to touch and itched. Reaction began less than 8-10 hours after vaccination (YF to right tricep lot# U1092AA on 7/17/2015, and Typhoid to right deltoid lot# K1183) and has grown over the last 10 days to cover the back of her arm. She believes it's worse today as the edges appear blotchy or hive like. She reports some swelling to this area with right arm larger than left and some weakness to her hand. She is right hand dominant. She also reported within 30 min of the 2 vaccines she was very tired and remains tired today. She denied any fever, chills, headaches, myalgia or arthralgia (nothing new) or any other systemic like reaction. She denies any change in ADL or inability to grip/use right arm....just says feels different. She has been self treating site reaction with topical BENADRYL, ice/heat without relief. She has not seen a HCP for this reaction. She reported she has had typhoid and YF vaccines in past as dependent prior to 2012 Olympics, however no documentation of past dependent vaccinations were identified in electronic records or hard copy medical records. (Research identified recommended vaccines for Olympics included routine adult vaccinations and YF, typhoid, meningitis, flu, hep A/B, tetanus, malaria. Exam: Musculoskeletal System: General/bilateral: Musculoskeletal system: normal grips equal and strong bilaterally with PROM bilateral upper extremities. Right hand dominant and reported to feel weaker than the left by patient. Denies numbness, tingling, paresthesia changes. States arm feels funny due to swollen tricep. Neurological: System: normal. skin: Normal with a roughly 10x8 cm slightly raised red oval shaped hive like rash surrounding YF injection site at right tricep. Area is mildly warm to touch and itches. There are several satellite red rashes surrounding primary red spot. No site reaction or swelling to right deltoid. Disc: Suspect this is a robust site reaction from YF vaccine (ingredients: porcine gelatin, egg) verses early booster administration of the YF vac. She advised she did participate in 2012 Olympics and had received YF/Typhoid vaccines prior to but was unsure of the year (trained for Olympics 2009-2012). Therefore if vaccine was given in this time period, a booster would have been due 2019-2022...and not in 2015...but no documentation of prior vaccination was found. Doubt adjuvant reactions as she has no reported egg allergy and does eat them. She did not have an anaphylactic reaction, but RAST testing can be considered to porcine gelatin (contained in MMR, YF, FLUMIST, FLUZONE). However she received FLUMIST in 2014 without reaction. Commonly reported side effects to YF vaccine includes fever, body aches, soreness, redness or swelling to injection site in 1 out of 4 individuals-onset can be up to 7-10 days post vaccination in some individuals. She advised her reaction began day of vaccination and persists as of day 10. Cellulitis was a consideration; however she remains afebrile and has limited site reaction. Will monitor response to topical steroid/NSAID use. She agree with this plan and will f/u with me in 48 hours, sooner if condition changes. Also for consideration for her arm weakness sensation is irritation of the brachial nerve due to inflammation from Typhoid vaccine and YF vaccines....as site inflammation resolves, pressure to surrounding nerves eases and symptoms resolve....(SIRVA study). Shoulder injuries related to vaccine administration (SIRVA) is a sequela to irritation of or inadvertent injection into or near the intracapsular space. Will monitor complaints once YF site swelling resolves.