Age: 60.0
Sex: F
Vaccine: TYP, YF
Symptoms: Acute kidney injury, Acute respiratory failure, Antiacetylcholine receptor antibody positive, Asthenia, Autopsy
Clinical narrative: This is an initial unsolicited literature case received via search of scientific literature on 20 March 2015: The following is verbatim from the aforementioned article full text: A female in her 60's, who was previously healthy and whose concomitant medications were not reported had received a single dose of yellow fever vaccine and a dose of typhoid vaccine (manufacturer unknown, route, site of administration and batch number were not reported for both the vaccines) on an unspecified date of September 2014. Six days post vaccination; the patient had experienced malaise, dyspnea, vomiting, and diarrhea of 3-5 days of duration because of which she was hospitalized in the emergency department. In the emergency department, the woman was afebrile but tachycardic and weak. She was admitted to the hospital with diagnoses of gastroenteritis, malaise, dyspnea, and throm-bocytopenia. Within 10 hours of admission, she experienced acute respiratory failure requiring intubation and mechanical ventilation. Contrast chest computed tomography indicated a substantial mediastinal mass. The patient experienced cardiogenic shock and acute renal failure (Ten hours after she was admitted to the hospital, her condition worsened, and she was put on a ventilator. She developed heart damage and kidney failure) and died 3 days after admission. Initial laboratory reports included a white blood cell count of 4,400 per microliter, platelet count of 84,000/ per microliter, potassium level of 2.8 mmol/L, and calcium level of 8.0 mg/dL. An autopsy was performed which revealed the thymus was diffusely enlarged, consistent with thymoma. The concentration of acetylcholine receptor binding antibody in blood collected 1 day before death was 0.88 nmol/L, indicative of myasthenia gravis. Tissue and serum samples were tested at CDC for evidence of yellow fever vaccine-associated viscerotropic disease (YEL-AVD), a serious adverse reaction resulting from the uncontrolled replication of vaccine virus and characterized by multisystem organ dysfunction; Immuno-histochemical staining indicated yellow fever virus antigen in tissue samples from various organs. Reverse transcription-polymerase chain reaction detected yellow fever vaccine viral RNA in multiple organs and in a serum sample that had been collected two days before death. Additionally, a serum sample obtained one day before death demonstrated evidence of yellow fever immunoglobulin M, with a yellow fever virus-specific neutralizing antibody titer of 640. Testing of yellow fever viral RNA from the vaccine lot used to vaccinate the patient identified sequences consistent with known vaccine strains without any notable mutations. The patient's clinical course and laboratory results, including her requirement for mechanical ventilation, platelets less than 100,000 per microliters, hypotension requiring vasopressor drugs to maintain systolic blood pressure, and increase in creatinine to greater than or equal to 1.5 times the upper limit of normal, met Level 1 diagnostic certainty for viscerotropic disease. The temporal relationship between yellow fever vaccination and development of symptoms was consistent with YEL-AVD. The presence of yellow fever virus-specific antigen in multiple organs demonstrated by immunohistochemistry, in addition to amplification of yellow fever 17D viral RNA from tissue, met criteria for definite yellow fever vaccine-associated causality. Both her age at vaccination and occult thymic disease likely predisposed this patient to YEL-AVD development. Documents held by sender: yes.