Age: 20.0
Sex: F
Vaccine: ADEN_4_7, FLU3, IPV, MNQ, TDAP
Symptoms: International normalised ratio normal, Itching scar, Livedo reticularis, Maternal exposure before pregnancy, Metabolic function test normal
Clinical narrative: This pleasant 22 y/o married patient was referred to Healthcare Center for Vaccine Causality Assessment following the patient's receipt of multiple vaccines on 02NOV12. The patient received the following vaccines on 02NOV12: (1) Adenovirus Type 4 and 7 #1 (live/oral); (2) IPV (inactivated); (3) IIV3 (inactivated); (4) MCG A, C, Y, W-135 Diphtheria Conj (inactivated) and (5) Tdap (inactivated). Two to three weeks later, the pt. reports the onset of itching, discoloration, hyperpigmentation, and sclerotic changes over the medial aspect of her right lower extremity (RLE). The skin changes skipped the medial aspect of her right calf and resumed just above the medial aspect of her right ankle. By early DEC 2012, the pruritus, hyperpigmentation and sclerotic linear areas extended up her right inner thigh and rt. inguinal area. She noted similar, but more subtle skin changes several weeks later over the left (Lt.) anterior and lateral aspect of her Lt upper thigh and Lt inguinal area, extending to her Lt anterior hip. The patient denies any viral or GI illness within 30 days prior to having her vaccines. She denies any facial, eye or lip swelling or any difficulty swallowing or wheezing in the first 15 min to 3 hours s/p receipt of vaccines. She does endorse some mild local erythema/edema at the injection site in one of her upper arms, which lasted about 2-3 days, but cannot remember which arm it was or which vaccine it was related to. She does not recall any systemic malaise, HA, chills, body ache, fever or generalized rash or hives during the first 7-10 days s/p receipt of her vaccines. However, record review indicates that on 09NOV12 (1 week s/p receipt of vaccines), the patient was seen for a c/o of 'lightheadedness/fatigue" stating she was "not used to doing physical activity in such humidity." From an immunological standpoint, these symptoms could be related to a "cytokine surge" one week s/p her receipt of multiple vaccines. She was evaluated for dehydration and to r/o anemia (Hgb 11.0 L / Hct 32.5 L). On 11NOV12 she was found to be G6PD deficient (6.6L), but Sickle Cell Negative. Her family history (FH) is significant for a maternal aunt with sickle cell, as well as a + FH of sarcoidosis. The patient endorses that sometime mid to late November 2012, she began to experience an "irritation, itching and change in color" (purplish brown hue) over the inner (medial) aspect of her right (rt.) lower leg, just below her rt. knee. The patient thought it was simply an irritation or chafing from her skin rubbing against her uniform pants and applied OTC lotion on the affected areas w/o significant relief of her sx. By early Dec of 2012, she noticed that the skin over the inner aspect or her rt. leg, from below her knee all the way up her rt. inner thigh looked purplish brown and seemed rough and thick. Again, she did not seek medical attention, as she began AIT on 26DEC12, immediately after completing her Basic Training. She completed AIT on 26FEB13. She arrived at new location on 27FEB13, where she joined her husband. Per medical record review, the patient in-processed at Occ Health on 20MAR13. She was seen at Health Clinic on 26MAR13 for Seasonal Allergic Rhinitis and treated with Loratadine 10 mg po qd, MUCINEX D 1200 /120 mg XR tab 1 po Q 12h. There were not any critical items noted on her PHA on 03APR13. She saw PCM on 16APR13 for a Women's Wellness Exam / PAP- Dx BV, Rx w/ FLAGYL 250 mg po BID x 5 days. HCG Neg. Started ORTHO TRI-CYCLEN LO (28-day). (16APR13) URI (post-nasal drip vs. allergies) seen at Health Clinic, Rx w/ MUCINEX/AFRIN. (30APR13) Serum HCG POSITIVE. LMP 26MAR13. Ref OB Clinic. (07JUN13) HCG repeated negative s/p TA, secondary to concern for possible worsening of her symptoms during pregnancy. (25JUN13) Patient reported h/o "discoloration and hardening of skin over right inner thigh" with onset 2-3 weeks s/p receipt vaccines to PCM. Sx have gradually progressed up her thigh and down below her knee. Denies hx of known injury or pain. (25JUN13) US / Right Lower Extremity Venous Duplex with no evidence of DVT. REF to Peripheral Vascular Medicine, Primary Dx: Thrombophlebitis of Extremity Superficial Vessels. (27JUN13) Reason for visit: thrombophlebitis. Spoke w/ Dr. (Hematology) re pt. case. Recommends stopping OCP's. Obtain LABS/clotting factors, start LOVENOX daily x 2 weeks. Will also start antibiotics (KEFLEX 500 mg 1 cap pot BID x 10d). F/U in 2 wks. (16JUL13). Schedule F/U appt with MD. Please note HIGH ANA and re-evaluate regarding phlebitis. (14AUG13) US, Venous Lower EXT DVT, Provisional Dx: Possible superficial thrombophlebitis of right great saphenous vein (GSV). (15AUG13) CONSULT Vascular Surgery. 21 y/o with progressive SVT. Please evaluate. Pt. reports onset of hyperpigmentation of the right inner thigh and calf several months ago. This area was pruritic, but never painful. Denies any characteristic cords. Deep venous duplex 25JUN13 was negative for DVT; saphenous system was not evaluated. Pt. now notes recent onset of similar hyperpigmentation of the left hip and flank area. Physical Exam: Blotchy hyperpigmentation and induration right medial thigh and calf. No discrete cords palpated. No edema. No varicosities. Blotchy hyperpigmentation left hip and flank area. IMPRESSION: Possible resolved SVT. PLAN: Repeat venous duplex in my lab with attention to superficial venous system. If GSV is completely thrombosed, no further therapy will be likely needed. If GSV is normal, consider DERM work-up. (10SEP13) LMP 05SEP13. 21 y/o F for f/u of hyperpigmented areas now on both legs. Was seen by Vascular Surgeon on 15AUG13, but patient not able to obtain F/U appointment as directed. No FH of CVD or rheumatologic disorders. No personal hx of prior hyperpigmentation. No hx of easy bruising. Patient is G6PD deficient. Patient is not on any meds prior to condition. Recently had wisdom teeth removed. Given Rx with KEFLEX. No problems w/ bleeding. A and P: 1. Thrombophlebitis of Lower Extremity Superficial Vessels appears resolved, but now has newer lesion on left leg. DOES NOT SOUND LIKE THROMBOPHLEBITIS. Also with increased ANA and ESR. Either way now, initial condition resolved w/ residual hyperpigmentation. Will repeat ANA and ESR to re-assess and REFER TO DERM for evaluation and treatment of hyperpigmentation, if possible. F/U with Vascular Surgeon in 1 month- has d/c'd OCPs due to possible clotting. Discussed other options w/ pt. Will consider IUD vs. diaphragm vs. condoms alone. Will f/u 1 month. Will not renew profile; patient should be able to do PT at this point. (18SEP13, 1317) Re Abnormal Lab results. Elevated ANA / ESR repeated- ESR 20 mm /hr. (was 40 mm/hr.). ANA 1:640 H w/ speckled pattern. Pt. has REF to DERM. Will REF to RHEUM / INT MED for eval possible underlying systemic conditions. (13NOV13) Clinic, RHEUMATOLOGY 21 y/o F referred for skin changes. Noted onset of RLE skin changes NOV 2012. (07JAN14, 0900) LMP 06DEC13. CC F/U. 21 y/o F patient Dx: LINEAR MORPHEA (25SEP13, punch biopsy). Has 2nd appt with RHEUM in 3 days. Was being initially treated w/ steroid long taper / burst. Sx essentially unchanged. Jogging currently, but if she runs hard, her scars will begin to itch and burn. No longer taking PNVs. Patient was seen Vaccine Clinic and will report condition to VAERS. IRILO not started yet, as not sure if patient meets criteria for same. A and P: 1. Resume PNVs- married/using condoms; 2. LINEAR SCLERODERMA- will await results/recommendations/prognosis from Rheumatology to ascertain if meets criteria for IRILO. Also await eval Vaccine Clinic. Profile updated to allow running at own pace and distance beyond 100 yds. F/u 1 month.