Age: 21.0
Sex: M
Vaccine: TYP, YF
Symptoms: Nausea, Orthostatic hypotension, Pyrexia, Vomiting
Clinical narrative: From initial information received on 12/08/03 through an enhanced surveillance program conducted by the CDC (VAERS ID 029810) regarding an adverse event occurring in the USA, it was reported that a 21 year old male in the military received typhoid vaccine and yellow fever vaccine on an unspecified date.  The manufacturers, lot numbers, routes and sites of administration were not reported.  30 minutes after receiving the vaccines, the pt experienced headache, chills, myalgias, arthralgias, nausea and emesis.  He was also orthostatic and febrile to 102.6 degrees Farenheit.  He was assessed as having a severe flu-like reaction with hepatocellular damage, mild subclinical disseminated intravascular coagulation (DIC) and bone marrow production abnormalities.  He was hospitalized for one week and recovered.  Additional information was provided on 12/15/03 from the CDC and included the VAERS form and a copy of a literature report entitled "Severe Systemic Reaction to Typhoid Vaccination: Two cases and a Review of the Literature" which was published in Military Medicine, Vol. 155, June 1990.  The pt received typhoid vaccine usp, manufactured by Wyeth-Ayerst and yellow fever vaccine (live virus), manufacturer not reported on an unspecified date.  The pt had been previously healthy and presented to the ER complaining of a sudden onset of headache, chills, myalgias, arthralgias, nausea and emesis within 30 min of receiving both vaccines.  He was markedly orthostatic and febrile to 102.6 degrees Farenheit (measured approximately 3 hours post-injection), but exam was otherwise unremarkable.  Admission CBC revealed mild leukopenia and anemia (WBC count= 2,800 cells/microliter; differential = 81% seg/15% bands/4% lymph; Hgb: 13.2 gm/dl; Hct: 39.9%) Prothrombin time was slighty prolonged at 13.2 seconds (normal range 9.0 to 12.0 seconds) with normal partialthromboplastin time.  Serum electrolytes were normal except for decreased potassium at 3.3 mHg/L (normal 3.5 to 5.3 mHg/L).  Creatinine was mildly elevated at 1.7 (normal 0.5 to 1.4), with normal BUN.  Transaminases were elevated (AST: 272 and ALT: 217, normal ranges 10 to 42 and 10 to 60 respectively) with total bilirubin of 2.4.  LDH was 457 (91-180) and CPK was 764 (22-269).  Urinalysis was normal except for the presence of hemoglobinuria or myoglobinuria.  Several potential nonvaccine-related etiologies were rules out with negative blood cultures, monopot, hepatitis panel, Coomb's test, EBV titers, and circulating anticoagulant screen.  A marked subjective improvement occurred over the first 24 to 48 hours, but ongoing laboratory abnormalities necessitated a week-long hospitalization.  He developed a leukocytosis (peak WBC count 14,400 cells/microliter) with left shift and lymphocytopenia, thrombocytopenia with nadir at 97,000 cells/microliter and mild subclinical DIC (partial thromboplastin time increased to 53 sec, fibrinogen decreased to 172 mg/dl [200-400] and fibrin split products increased to 32 microliter/ml [0-8].  The CPK peaked at 1411.  Bone marrow aspirate and biopsy were done to rule out infiltration (i.e. leukemia) and revealed normal cellularity, poor maturation of the myeloid series, and severe lymphocytopenia.  All abnormalities resolved unremarkably over days to weeks.  It was assessed that the pt had a remarkably severe influenza-like reaction, with hepatocellular damage, mild subclinical disseminated intravascular coagulation (DIC) and bone marrow production abnormalities.  The pt's clinical picture was felt to be most consistent with a reaction to typhoid vaccine.  No other information was provided.  Other manufacturer's report number is 8-91078-002B.