Age: 37.0
Sex: F
Vaccine: FLU3, PPV
Symptoms: Blood culture negative, Body temperature increased, Chest X-ray normal, Chills, Dermatitis bullous
Clinical narrative: Initial and follow up information has been received from a health care worker and medical records concerning a 37 year old female registered nurse, non smoker, with no allergies. The patient has a history of left ovarian cyst removal, psoriasis and keloid. On 01-OCT-2008 at 12:00PM (previously reported as 30-SEP-2008) the patient was vaccinated with a second dose of PNEUMOVAX (lot # 660717/0224X) 25 mcg/0.5 mL intradermally, instead of tuberculin purified protein derivative (manufacturer unspecified). Concomitant medication included AFLURIA (lot# 02249111A) IM in right deltoid at 12:00PM, CLARITIN D 12 HOUR and Multivitamin (unspecified). There was no illness at the time of vaccination. Subsequently the patient experienced injection site swelling, redness and pain. On 02-OCT-2008 at 12AM, the patient presented to the clinic with chief complaint of a reaction to a tuberculin (TB) test. She stated that her arm was very painful and burning. She had no history of positive purified protein derivative (PPD). Her blood pressure was 140/88 and her temperature was 98.4 degrees. Examination showed that the volar surface of the left forearm revealed a 5 cm area of induration, a 5+cm area of erythema, and 1 cm area of induration in the center. Assessment was positive PPD with probable severe local reaction, cannot rule out early cellulitis. A chest x-ray with indication of positive PPD, was normal. The patient was given a prescription for KEFLEX, to start if erythema continued to spread. On 03-OCT-2008 at 12:00 AM, the patient presented to the hospital with chief complaint of left arm redness, swelling and pain x 2 days that worsened. Since the clinic visit on 02-OCT-2008, she has had associated chills with red streaks up her arm and severe pain and tenderness. The error in the administration of the PNEUMOVAX vaccine rather than tuberculin reagent was discovered late in the afternoon, and she was admitted to the hospital for further treatment. Physical examination revealed a temperature of 36.9, pulse 108, blood pressure 132/60. Integument revealed a well-demarcated, large raised red patch, volar aspect left forearm, with incipient central bullous formation. The area was exquisitely tender. There was red streaking up the arm, coursing toward the axilla. The assessment was left upper extremity cellulitis after inadvertent subcutaneous injection of PNEUMOVAX, with no response to p.o KEFLEX, and systemic symptoms of chills and streaking and incipient bullous formation. Treatment included observation, intravenous Vancomycin 1 g every 12 hrs and IV ceftriaxone 2 g every 12 hrs as well as warm compresses, arm elevation and TYLENOL #3 as needed. On 03-OCT-2003 results from blood culture and culture and sensitivity came back negative and the final report showed no growth after 5 days. Blood differential showed absolute blood monocyte count of 1.0 K/uL (reference ranger: 0.0-0.8). On 05-OCT-2008, the patient had an infectious disease consultation. The physician noted that the patient was also on chewable calcium and antiemetics (unspecified) PRN. During the consult, she was not febrile and both pain and erythema were resolving. The consults impression was left arm cellulitis. The recommendation was to continue the intravenous antibiotics and the patient could be released on 06-OCT-2008 on oral doxycycline for the next few days. She should also continue to apply warm compresses. A vancomycin through done on 05-OCT-2008, came back with a value of 4.8 mcg/mL (reference rang 5.0-15.0). On 06-OCT-2008, the patient was discharged, she had some residual induration at the site of her subcutaneous injection. Her discharge medications included doxycycline 100 mg twice daily. Her discharge diagnosis was left upper extremity cellulitis occurring after inadvertent subcutaneous injection of PNEUMOVAX vaccine with intense, inflammatory reaction. She was to follow up with her primary physician in a week. On 13-OCT-2008, the patient was seen in the clinic. The physician's exam revealed that she had a faint erythematous patch, left volar forearm centrally indurated, mildly tender area, measuring 3-4 cm. The left arm cellulitis was resolving. This is one of two reports received from the same source. Additional information is not expected. All records will be available upon request.