Age: 83.0
Sex: M
Vaccine: VARZOS, VARZOS
Symptoms: Anti-cyclic citrullinated peptide antibody positive, Arthralgia, Arthritis, Blood uric acid normal, Bone cyst
Clinical narrative: Information has been received from a registered nurse concerning a 83 year old male patient who on 14-DEC-2010 was vaccinated subcutaneously with 0.65 mL of ZOSTAVAX (Merck (lot # 669264/1363Z) and expiration date 15-JAN-2012. Concomitant therapy included ASMANEX, prednisone, nabumetone, hydrocodone and oxycodone. The nurse reported that about 1 week after the patient received ZOSTAVAX (Merck) on approximately 21-DEC-2010, the patient experienced swelling in his hands, arm and shoulder which progressed to joint aching. At the time of the vaccination, the patient was taking 10 mg prednisone daily. The patient sought medical attention and was diagnosed with rheumatoid arthritis by an unspecified physician. Since this experience the patient had been prescribed different medications for control of pain and prednisone. At the time of the report, the patient had not recovered. Follow-up information was received from a physician and medical records regarding an 83 year old male (165 pounds, 67 inches) with no known drug, food or contrast media allergies, chronic obstructive pulmonary disease (COPD) treated with steroid therapy (prednisone) and oxygen therapy at night, shortness of breath (SOB), prostatism, left shoulder pain, arthritis and a history of pneumonia, accidental fall, gout (remote history; in his 60's), bilateral total knee replacements, appendectomy and tonsillectomy who on 08-DEC-2010 was vaccinated with ZOSTAVAX (Merck) (lot # 669624/1363Z) intramuscularly (site not reported). On 18-DEC-2010, the patient was seen in the emergency room for a swollen arm and achiness all over. He was told he had an infection and placed on cephalexin and diclofenac. On 21-DEC-2010, the patient saw his physician who reported: "In the past when there has been a flare up of his arthritis, prednisone has worked on him." The examination showed the patients hands were actually down quite a bit but overall were still quite tender, slightly swollen and warm to the touch. His uric acid was 5.0 mg/dl "as he has had the gouty-type arthritis before". The assessment was degenerative arthritis and prednisone 10 mg decreasing down was prescribed. On 24-JAN-2011, the patient saw his physician with complaints of some shortness of breath for a few days and dizziness and a little lightheadedness over the last couple of days. Assessment was labyrinthitis and dyspnea. On 28-JAN-2011, the patient was seen in the emergency room for chronic obstructive pulmonary disease exacerbation and treated with steroids. On 02-FEB-2011, the follow-up visit assessment was chronic obstructive pulmonary disease exacerbation, resolved. On 04-MAR-2011, the patient complained of what he described as rheumatism in multiple different joints which included right elbow and hand and left wrist, which came and went. Nabumetone was prescribed for arthritis pain. On 11-MAR-2011, patient was seen with significant swelling and pain of his left wrist and some discomfort in the rest of his joints as well but nothing as severe as his left wrist. A left wrist x-ray showed tremendous osteoarthritis and inflammation in the wrist itself. The ulnar styloid was reported as being abnormal. This was thought not to be an acute fracture but maybe scar tissue and deformity from a fall about 2 years ago. His uric acid was 6.6 mg/dl. Left wrist osteoarthritis was assessed and prednisone was given. On 04-MAY-2011, patient seen for right wrist pain which was similar to his previous left wrist pain. It was noted the prednisone burst seemed to be helping. The assessment was right wrist osteoarthritis. On 21-MAY-2011, the following laboratory tests were performed: uric acid: 6.1, mean corpuscular volume: 95.5 fL, lymphocytes: 0.62 x 10 (9)/L, sedimentation rate: 60 mm/l, rheumatoid factor: 460 IU/mL ("largely elevated"), C-Reactive Protein: 135.4 mg/L and cyclic citrullinated peptide: >250.0 U. A cervical spine x-ray done for neck pain: mildly cervical instability with grade 1 anterolisthesis C3 on C4 on vertebral body. Old fracture C4 vertebral body. Degenerative changes with disc space narrowing most prominent at C4-5. Mild grade 1 retrolisthesis and calcification of the nuchal ligament at C4-5 and bilateral hand x-rays were done for pain and swelling of both hands: moderate degenerative changes at the radiocarpal, ulnocarpal and distal or radial ulnar joint bilaterally with some osteoarthritic irregularity of the ulnar styloids bilaterally. Degenerative subchondral cysts distal left radius. Moderate degenerative changes in the 1st carpal metacarpal joint bilaterally and the left 1st metacarpophalangeal joint. There is slight medial subluxation of the left thumb at this joint. Scattered mild interphalangeal joint degenerative changes bilaterally. No fractures. On 22-May-2011, patient presented to the emergency room for suspected gout with bilateral hand pain and swelling. A left shoulder x-ray for likely new diagnosis of rheumatoid arthritis was done which showed mild hypertrophic degenerative changes of the left shoulder with slight rotator cuff arthropathy. No fractures or obvious joint effusion. On 08-JUN-2011, the patient was seen for ongoing bilateral hand swelling which spontaneously started in January 2011 and had been persistently bothersome since that time. Impression: seropositive rheumatoid arthritis. The final diagnosis was bilateral hand edema and arthralgias. On 16-JUN-2011, the patient was seen in follow-up with some achiness in his wrists and hands. The assessment was: chronic obstructive pulmonary disease stable on prednisone taper and rheumatoid arthritis undergoing treatment with methotrexate. On 14-JUL-2011, sedimentation rate was 56 mm/hr. The physician reported that subsequently the patient was diagnosed with rheumatoid arthritis. He had no previous history of rheumatoid arthritis symptoms. The physician indicated the rheumatoid arthritis resulted in permanent disability. At the time of this report, the rheumatoid arthritis was ongoing. All available medical records will be provided upon request. Additional information has been requested.