Age: 17.0
Sex: F
Vaccine: MEN, MEN
Symptoms: Rash erythematous, Vasculitis
Clinical narrative: From faxed correspondence received at manufacturer on 10 JUN 2002 from a physician's office, it was reported that a 17 year old female patient received Menomune vaccine on 07 MAY 2002. Patient developed petechial erythematous rash (some flat lesions, some raised) on lower extremities on 18 MAY 2002. Patient with no complaint of discomfort, referred to Dermatology and was seen on 22 MAY 2002. Rash increased up to legs and elbows when seen on 03 JUN 2002, treated with topical steroids. Slight edema noted in elbows. Complained of ankle and elbow pain. Large amount of blood noted in Urinalysis. On 4 JUN 2002, patient admitted by rheumatologist. Treated with steroids and diagnosed with Henoch-Schonlein purpura. On 8/2/02, during internal review of reports it is deemed necessary to add the adverse event onset date of 5/18/03. This info was previously captured in the narrative section. From follow-up correspondence received at manufacturer on 8/12/02-a telephone call was made to pediatric. It was reported that the pt has not recovered, possibly kidney involvement, awaiting the results of testing. From additional information received on 21/Jan/2004 from a literature citation, it was reported: At prsentation, a physical examination revealed an otherwise well teenager with muliple purpuric papules, some with darker centers and purpuric halos and others with central ulceration on the bilateral lower extremities, buttocks, volar hands and left elbow. She denied having abdominal pain, hematuria, fever, cough or change in bowel movements. In the next couple of weeks, new lesions developed on bilateral elbows and ankles, and existing lesions progresses to hemorrhagic bullae and then to more prominent purpuric bullae and ulcers. Clobetasol cream twice a day, rest and lower extremity and elevatiojn wer prescribed. Initially, She was withouth rhematolgic complaints, but polyarthritis and bilateral lower extremity edema and pain with difficulty walking at the end of the day developed over the next week. The preexisting treatment regimen was augmented with hydrocolloid dressing (DuoDerm Extra Thin) over the ulcers and mild compression stockings. The original ankle skin biopsy demonstrated an infiltrate of neutrophils and karyorrhectic debris and fibrin within and around walls of superficial venules typical of LVC. A subsequent lesional skin biopsy taken for immunofluroescence revealed brightly positive granular staining surrounding and within superficial dermal vessel walls with IgA, consistent with HSP. The initial complete blood count, chemistries, liver enzyme tests, and erythrocyte sedimentation rate were normal. Hepatitis C virus antibody and antinuclear antibody were negative. The urinalysis was without blood, protein or casts. Throat culture was negative for group A beta hemolytic streptococcus. Two weeks after disease presentation, a repeat urinalysis revealed a large amount of blood (performed when the patient was not menustrating). A hospital admission was deemed necessary because of the severity of the skin lesions and the debilitating arthritis. Although hospitalized, the patient had normal vital signs, mild left upper quadrant abdominal tenderness, and cervical lymphadenopathy. Chest radiograph, complete blood count, electrolytes, erythrocyte sedimentation rate, creatine phosphokinase, and complement levels were normal. Stool quaiac, antinuclear antibody, antineutrophil cytoplasmic antibodies, cryoglobulins, Lyme titers, and rhematoid factor were negative. A repeat urinalysis was negative for blood, protien, and casts. She was treated with prednisone, 60 mg daily and nonsteroidal anti-flammatory agents for her severe skin involvement and arthritis. The joint symptoms improved, and the skin lesions stopped progressing. She was discharged from the hospital 2 days after admission. Treatment with high dose prednisone was continued for 2 weeks and then slowly tampered over 6 weeks. Her ulcers healed slowly in the weeks after the hospital admission; a few minor purpuric papules on the ankles and feet persisted but resolved with topical clobetanol. Three months after the immunization, the patient developed 3 + proteinuria and 3+ hematuria but maintained normal blood pressure. Eight months after vaccination she presented with significant proteinuria (1.320 g/24 hours and 1.1 g/24 hours creatinine). A renal biopsy demonstrated mesangial proliferative glomerulophritis with IgA deposits compatible with mild HSP renal involvement. Maxema was begun, and 2 months later a follow-up 24-hour urinalysis revealed creatinine of 0.9 g, blood urea nitrogen of 20g, and urine protein of 1.030 g. The patient has mild nephropathy thought to be secondary to HSP. It has not worsened over the ensuing several months and is not expected to worsen in the future.