Age: 5.0
Sex: F
Vaccine: MEN, PPV
Symptoms: Activities of daily living impaired, Blood culture negative, Headache, Inappropriate schedule of drug administration, Injection site erythema
Clinical narrative: This is a literature report. A 5-year-old female patient of an unspecified ethnicity received four doses of pneumococcal 7-valent conjugate vaccine (MANUFACTURER UNKNOWN), 1 dose of pneumococcal 13-valent conjugate vaccine (MANUFACTURER UNKNOWN), second dose of meningococcal conjugate vaccine (MANUFACTURER UNKNOWN), and 2 doses pneumococcal polysaccharide vaccine (MANUFACTURER UNKNOWN), all via unspecified routes of administration on unspecified dates at single doses. Medical history included sickle cell-hemoglobin C disease, chronic splenomegaly, recurrent otitis media, requiring placement of tympanostomy tubes, leg pain, headache, asthma, low grade fever after receiving vaccinations, which was treated with ibuprofen, urticarial response to fire ant bites, and skin test confirmed allergies to dust, mold, mildew and cockroaches. The patient's concomitant medications were not reported. The patient previously received the hepatitis B vaccine series, annual influenza vaccines, and the first dose of meningococcal conjugate vaccine. On unknown dates, the patient experienced severe arm swelling with edema to the extent that it was difficult to put a shirt over the arm, which was serious for hospitalization. The clinical course was as follows, the patient presented with arm swelling, redness and pain as well as fever and nausea after immunization during a routine follow-up visit the day before. In her previous clinic review, she reported leg pain that sometimes required pain medication and headache pain in the past 4 weeks. She also had chronic splenomegaly from her sickle cell disease. At this visit, she received the PPSV23 in her right arm and meningococcal conjugate vaccine in her left arm. The patient's immunization history included one dose of the PPSV23 two and a half years earlier and a dose of the meningococcal conjugate vaccine 6 months prior to the event. She also had received four doses of the 7-valent conjugated pneumococcal vaccine and one dose of the 13-valent conjugated pneumococcal vaccine. The patient developed pain in her head, neck and arm and a fever of 102.9 degrees F in the early morning the day after receiving the PPSV23 and meningococcal conjugate vaccine. Her mother administered ibuprofen. Ten hours later, the mother reported a fever of 101.3 degrees F and right arm swelling with edema to the extent that it was difficult to put a shirt sleeve over the arm. The patient was brought to the hematology clinic where she received ketorolac for pain and ondansetron for nausea reported at the clinic. Upon examination, it was noted that the right arm was tender with redness over the lateral aspect and swelling down to the elbow. She received one dose of intravenous ceftriaxone, but blood culture was subsequently negative. She was discharged from the clinic with ibuprofen and morphine for break-through pain. The swelling in the right arm resolved at home within 24 hours. Per the authors, this patient was a young girl with sickle cell disease who presented with fever and limb swelling after a second vaccination with both PPSV23 and the meningococcal conjugate vaccine. Of note, she had received multiple doses of pneumococcal vaccines, and the PPSV23 vaccination associated with this event was administered only 2.5 years after the previous PPSV23-earllier than the 3 years recommended by guidelines. Additionally, she was 5 years old at the time of the limb swelling. With a score of three from the Naranjo Algorithm for determining adverse events, the case report described above could be considered an adverse drug event. Since the swelling occurred in the same arm as the 23-valent pneumococcal polysaccharide injection and since it was the second PPSV23 vaccination, it is likely that PPSV23 caused the adverse event. It is possible that administering PPSV23 earlier than the recommended 3 years and repeated exposures to polysaccharide capsule antigens may have been contributing factors. Additionally, the immune reaction might have been amplified by the conjugated meningococcal vaccine administered concurrently in the other arm. Finally, the pain that occurred before and during the arm swelling might have been at least partially related to sickle cell vaso-occlusion.