Age: 15.0
Sex: F
Vaccine: HEP, VARCEL, HEP, VARCEL
Symptoms: Asthenia, Dehydration, Dizziness, Headache, Hypokinesia
Clinical narrative: pt recv vax;30jun95 pt devel 10-15 lesions;01jul95 seen in MDs ofc w/ HA & v;was noted to be dehydration & ataxic;01jul95 pt hosp for fluid replacement;discharge on 2jul95 w/ dx of dehydration;  Received on 09/22/2000: "Information has been received from a physician concerning a 15-year-old caucasian female with a history of recurrent headache, sinusitis, and allergic rhinitis who on 06/05/1995 was vaccinated subcutaneously or intramuscularly (both routes were reported) in the left arm with her first dose of varicella virus vaccine live (Lot # 608310/0400B).  She was vaccinated, on the same day, intramuxcularly in the right arm with a first dose of hepatitis B vaccine (Engerix B Lot # ENG1657A2).  Other concimitnat medication included loratadine (Claritin).  On 06/28/1995 or 06/30/1995 the patient broke out in a rash.  She developed 10-15 circular lesions, primarily on her trunk and extremities.  The lesions were not on rose colored base, they were flesh colored.  There was no evolution to crusts.  They were not typical of chicken pox.  On 06/30/1995 or 07/01/1995, she experienced severe headaches.  Vomiting which was severe, retching, and dry heaving.  On 07/01/1995, she experienced lethargy, ataxis, and she moved slowly.  On the same date, she was seen in the emergency room and was hospitalizedd for dehydration.  She was hydrated with IV fluids.  The treating physician could not confirm the emergency room resident's impression of ataxis.  A lumbar puncture was not done.  A scraping of one of her lesions, which was taken after the scyclovis was started, was cultured and no viruses were isolated.  No were sent for PCR analysis.  She was treated with acyclovir (Zovirax) 200mg four times a day for five days, and prometharine HC1 (phenergen).  The patient was discharged on 07/02/1995 with a discharge diagnosis of dehydration and "varicella reaction", the discharging physician reported in his note that the patient was "up, looking great and eating" on the day of discharge.  The physician reported that both the patient and her sister were "known to the staff as tending to dramatize things".  The patients sister (WAES 95080882) had a similar experience following exposure to varicella virus vaccine live.  On 07/10/1995 the patient was seen by her physician and it was reported that the patient was still "real tired" and walked slowly.  Her blood pressure sitting was 102/56.  The "Tsanc prep" labs were reported pending.  As of 07/26/1995, the patient had recovered "from her illness".  On 10/23/1995, the patient presented to a physician due to chronic dizziness.  Laboratory evaluation included a "work-up" for mononucleosis and vertigo, both of which were negative, and a negative electronystagmogram.  The patient was referred to a neurologist.  The neurologist sated that he saw the patient on 12/19/1995.  An EEG was normal, and she was treated for migraine activity.  The neurologist also stated there was "no apparent ataxis", but there was vertigo, possible migraine activity and chronic headaches possibly cause by the vaccine which "may be causing an ataxis status in the patient".  Upon further review of this case, it was felt that ataxis should be removed as an adverse event because the ataxis was never confirmed in this patient.  this is an amended report information added, included the following: Lot #  and site of vaccination, several changes to the narrative, and the patient's blood pressure to diagnostic test field.