Age: 63.0
Sex: M
Vaccine: YF, YF, HEP, HEPA, TYP
Symptoms: Jaundice, Laboratory test abnormal, Pyrexia, Rash maculo-papular, Vomiting
Clinical narrative: Information has been received from a health professional, through an enhanced surveillance program conducted by the Centers for Disease Control and Prevention and from the CDC minutes of the Yellow Fever Meeting on 2/9/04 concerning a 63 year old male patient with a history of a head cold and a cough for approximately two weeks prior to vaccination with yellow fever virus vaccine who on 1/28/04 was vaccinated with a dose of hepatitis A virus vaccine inactivated. Concomitant vaccination on 1/28/04 included a dose of hepatitis B virus vaccine and dose of typhoid vaccine. Concomitant vaccination on 1/29/04 included a dose of yellow fever virus vaccine. On 2/2/04 the patient developed vomiting, chills, fever, dizziness, hemoptysis, low back pain, headache and possible delirium. On 2/3/03, the patient began to develop jaundice. The patient lost his appetite and lost approximately nine pounds in four days. On 2/4/04, the patient went to the emergency room and was hospitalized for four days with symptoms of fever of 102.5 degrees F, jaundice, belly pain and chest pain. A sputum culture was positive for strep pneumonia and the patient had high bilirubin. The patient had a macular papular rash on the right side of his back. The admitting diagnosis was strep pneumonia and yellow fever vaccine reaction. The treating resident did not think the strep pneumonia was the cause of the patient's jaundice and the liver problem. On 2/7/04, the patient left the hospital. The CDC received one sample of the serum that had been collected from the patient on 2/4/04. A 500 microliter blood sample was forwarded and was tested by TagMan using two standardized primers. It tested positive at CT 36 and at CT 35.5 and the interpretation of these results needed to be performed with caution provided the cycle time. Testing by PCR was under way and virus isolation was to be attempted after cell culture. TagMan RT PCR tests results were positive for YF 17-D. Given the specifics of the test results, the doctor did not feel that he was likely to get any isolate from attempted culture of this specimen, so standard RT PCR was performed as a special investigation to try to amplify a fragment for sequencing, which was not successful. The sample was negative on ELISA for a variety of agents including YF, WEE, EEE, SLE, VEE, MAY, Dengue 1-4 and West Nile Virus. The sample was negative on IgM and IgG ELISA on all of these. The sample volume was quite small. No other testing was pending since no more sample was available. On 2/20/04, the patient had no detectable IgM or IgG antibodies against yellow fever. The testing facility received a second serum sample, which was collected from the patient on 2/24/04. This sample was negative on PCR for YF 17-D RNA, YF IgM positive on ELISA and YF IgG negative on ELISA. The patient's recovery status was not reported. The file is to be completed. Follow up on 05/28/04 states: "Pt with non-insulin dependent diabetes mellitus (takes no medication), hypertension (takes no medication), a history of a head cold and a cough for approximately 2 weeks prior to vaccination with yellow fever virus vaccine, military service (did not receive any previous YF vaccine) and travel to another country for work (1994) (did not receive any shots) who on 01/28/04 was vaccinated with a dose of hepatitis A virus vaccine inactivated (manufacturer unknown)(manufacturer, lot # route and site not reported). Concomitant vaccination on 01/28/04 included a dose of hepatitis B virus vaccine rHBsAg (yeast)(manufacturer unknown, lot #, route and site not reported) and a dose of typhoid vaccine (unspecified)(manufacturer, lot #, route and site not reported). Concomitant vaccination on 01/29/04 included a dose of YF virus vaccine (Lot # site and route not reported). On 01/02/04 the pt developed vomiting, chills, fever, dizziness, hemoptysis, low back pain, headache and possible delirium. Hematemesis was noted. On 02/03/03, the pt began to develop jaundice. Scleral icterus was noted. The pt lost his appetite and lost approximately 9lbs in for days. On 02/04/04, the pt went to the ER and was hospitalized for four days with symptoms of fever of 102.5 deg F, jaundice, belly pain and chest pain. A sputum culture was positive for strep pneumonia and the pt had high bilirubin. Pneumonia streptococcal was noted. See lab section for additional testing performed during the pt's hospital stay. The pt had a macular papular rash on the right side of his back. The admitted diagnosis was strep pneumonia and yellow fever vaccine reaction. The treating resident did not think the strep pneumonia was the cause of the pt's jaundice and the liver problem. On 02/07/04 the pt left the hospital. The CDC received one sample of serum that had been collected from the pt on 02/04/04.  A 500 microliter blood sample was forwarded to another facility and was tested using two standardized primers. It tested positive at CT 36 and at CT 35.5 and the interpretation of these results needed to be performed with caution provided the cycle time. Testing by PCR was underway and virus isolation was to be attempted after cell culture. RT-PCR test results were positive for YF 17-D. Given the specifics of the test results (count values), the doctor did not feel that he was likely to get any isolate from attempted culture of this specimen, no standard RT-PCR was performed as a special investigation to try to amplify a fragment for sequencing, which was not successful. The sample was negative on ELISA for a variety of agents including YF, WEE, EEE, SLE, VEE, MAY, Dengue 1-4 and West Nile Virus. The sample was negative on IgM and IgG ELISA on all of these. The sample volume was quite small. No other testing was pending since no more sample was available. On 02/20/2004, the pt had no detectable IgM or IgG antibodies against yellow fever. Another facility received a second serum sample, which was collected from the pt on 02/24/04. This ample was negative on PCR for YF 17-D RNA, YF IgM positive on ELISA (P/N 14.6) and YF IgG negative on ELISA (P/N 1.6). The pt's recovery status was not reported. The file is to be completed."