Age: 76.0
Sex: F
Vaccine: FLUX
Symptoms: Eye swelling, Face and mouth X-ray abnormal, Gram stain positive, Groin pain, Haematocrit decreased
Clinical narrative: Initial case was retrieved from the scientific literature on 10 February 2012. The following is verbatim: "This 76 year old woman was admitted to [a hospital] on October 27, 1972, because of unexplained fever. Two weeks earlier, she noted fever and malaise, the day after her annual "flu" immunization. A week later she had headache, jaw pain, fever, chills, aching muscles, abdominal pain, intermittent blurring of vision, and swelling of her left eye and the glands on the left side of her neck. One day before admission she had chills and her temperature rose to 104 degrees F. Past history included hepatomegaly of 20 years' duration (she had consistently refused biopsy), recurrent urinary tract infections and an episode of Escherichia coli bacteremia six years earlier. She was a thin, uncomfortable, elderly woman complaining of headache. Her temperature was 102 degrees F. Her liver was enlarged (17cm), but it was smooth and nontender. Both temporal arteries were unremarkable as was the remainder of the physical examination. Her hematocrit value was 31 percent, erythrocyte sedimentation rate 65 mm/hour (Westergren), white blood cell count 11,100/mm3 with 81 percent polymorphonuclear cells. Urinalysis revealed pyuria and bacteriuria; culture yielded >10^5 colonies/ml of Esch. coli. The platelet count was 761,000/mm3. Serum albumin was 2.9 g/100ml. Abnormal liver functions included SGOT (189 U), SGPT (308 U), and serum alkaline phosphatase (180IU); Bromsulfalein retention was 13 percent. The liver scan revealed multiple defects suggesting metastases. Cultures, serologic studies, skin tests, other chemistry studies, roentgenographic examinations and thyroid studies were unrevealing. Her temperature rose to 102 degrees F each evening the first four days. On the fifth day, it fell to 100 degrees F, she felt improved and her appetite returned. Because of persistent fever, headache and "blacking out" spells, a lumbar puncture was performed. Spinal fluid was normal except for a protein level of 77 mg/100 ml. Her frequent spells of "blacking out" were then recognized as episodes of decreased vision in the right eye, which revealed a blurred, pale optic disk; the left eye was normal. Biopsy of the palpably normal left temporal artery revealed arteritis but no giant cells. The administration of prednisone (90 mg/day) was begun, and her fever promptly abated. Sulfisoxazole was prescribed for her urinary tract infection. Despite striking clinical improvement, vision in her right eye worsened and disappeared completely after six days of prednisone therapy. The left eye was not affected. All liver function tests returned to normal. Her hematocrit value remained 30 percent, but the erythrocyte sedimentation rate decreased to 21 mm/hour after several weeks, and her prednisone dosage was decreased accordingly. Evening temperature elevations to 100 degrees to 100.2 degrees F recurred at that time. The source of this recurrent fever was not uncovered, despite repetition of most of the original studies. The patient was discharged after two months with continued low grade fever; prednisone dosage had been as low as 40 mg/day, but was increased to 60 mg/day when the erythrocyte sedimentation rate again increased to 28 mm/hour. The patient was readmitted 11 weeks later (March 10, 1973). In the interval, she remained weak, had occasional chills and evening temperatures of 100 degrees to 100.4 degrees F, but she refused to be rehospitalized. Two weeks prior to readmission, she noted pain in the right groin and thigh, which intensified two days before admission when her appetite abruptly disappeared. On admission she was acutely ill (temperature 101 degrees F) with erythema, induration and tenderness in the right groin and femoral area. Intravenous lincomycin (600 mg) was administered every 8 hours. She received 3 units of packed red blood cells since her hematocrit value was 23 percent. She showed defervescence in 72 hours, but the inguinal-femoral swelling increased and spontaneously drained purulent material on the 10th day. Culture yielded Esch. coli, but a gram-stain also revealed streptococci and gram-negative rods resembling bacteroides. Sinography revealed communication with a right retrocecal (psoas) abscess. This collection was drained through the flank, and the inguinal-femoral abscess then healed. She remained afebrile and the prednisone dose was reduced to 5 mg/day at discharge, with a hematocrit value of 32 percent and an erythrocyte sedimentation rate of 51 mm/hour. The liver scan was unchanged. Remission has been maintained for the ensuing two years with 5 to 10 mg prednisone daily; the hematocrit value is 40 to 45 percent, but the erythrocyte sedimentation rate remains increased (45 to 50 mm/hour). Comment: The abrupt onset of illness shortly following her annual "flu" immunization, although possibly coincidental, may have etiologic significant. Headache and intermittent loss of vision were more classic clues that led to prompt biopsy of the temporal artery. An unusual steroid-associated complication, occult perforation of the intestinal tract (appendiceal?), thwarted attempts to control the arteritis by monitoring her erythrocyte sedimenation rate." Documents held by sender: None.