Age: 4.0
Sex: M
Vaccine: DTAPIPV, HEPA, MMR, VARCEL
Symptoms: Injection site haematoma, Injection site papule, Injection site swelling, Pallor
Clinical narrative: 4 y/o male dependent child referred to clinic by provider for evaluation of "bruising & swelling" on child's left upper thigh, which mother noticed at 48 hrs s/p son's receipt of (inactivated) KINRIX & Hep A #2- (both) in left vastus lateralis on 06MAY11. Child also received (live) MMR #2 & Varicella #2 vaccines (sc) in right upper thigh on 06MAY11. Mother reports that patient "jerked a bit" upon receipt of KINRIX & Hep A in his left upper thigh. The mother denies that pt c/o of systemic malaise, fever, HA, chills or body ache s/p receipt of multiple immunizations (routine 4 y/o shots) on 06MAY11. She denied that patient developed any wheezing or difficulty breathing, swallowing or facial/lip/periorbital edema in the first 15-30 minutes or w/in 3 hrs of receipt of vaccines. The mother denied any changes in patient's energy level or appetite the next day. She denied that patient had any viral illness 30 days prior to or since receipt of his 4 y/o shots. The family ate out on (08MAY11) & the mother noticed that patient's left upper thigh looked red & swollen, but he was not limping or in pain. She raised the leg of his shorts up & there were (2) red circular "spots" on the child's left anterior thigh. One was about 3 cms in diameter & the other about the size of a quarter. When they arrived back home, she gave patient some children's BENADRYL elixir. When patient awoke the next morning, the two red spots on his left anterior thigh had disappeared, but his left upper thigh was still "red and had a purplish hew". Mother called clinic (09MAY11) for appt for patient. Provider documented "ecchymosis scattered blanching light erythema, nondescript over patient's anterior left thigh" - not sure if it was "drug reaction" or minor trauma w/ superficial bleeding under the skin, due to patient jerking his leg at the time of injection. Mother was advised to apply ice to the child's left upper thigh & to give patient children's OTC liquid TYLENOL prn pain till evaluation at clinic (10MAY11). PMH: No previous adverse reactions to vaccines, hospitalizations, surgeries or serious childhood illnesses. Several episodes otitis & one episode gastroenteritis (2008), per record review. Allergies: NKDA, no food/nut/shellfish/latex or environmental allergies. Child seen at clinic (10MAY11 3PM). In NAD- asleep in mother's arms, afebrile & cooperative upon awakening. Focused Exam: fair skin/blue eyes - blue veins readily visible beneath surface of light skin. Left upper thigh still slightly swollen & erythematous. A discrete, almost fading, fine papular rash noted on anterior & medial surface of child's left upper thigh & right upper arm w/ a 8x5mm fading hive-like macule near the right anticubital fossa. A&P: 1. Resolving erythema/edema left anterior thigh c/w large local reaction at injection site (s). PLAN: Continue to apple ice/cool compresses to affected area 20 min on/20 min off bid prn. Children's OTC liquid TYLENOL q 4-6h, as indicated on bottle, prn pain/malaise. 2. Resolving fine papular rash left anterior thigh & right upper arm (?) etiology - onset in temporal association w/ receipt multiple vaccines-probably c/w non-specific dermatitis post receipt of multiple vaccines. PLAN: Continue OTC children's BENADRYL elixir q4-6h prn (dose as indicated on bottle), until rash completely resolved. Cautioned re sedation - best given at hs. Call 911 or take child to ED if any acute respiratory distress, difficulty swallowing or facial/lip/periorbital swelling. Mother of child verbalizes understanding.