Age: 22.0
Sex: F
Vaccine: HPV4, HPV9
Symptoms: Onychoclasis, Pain, Palpitations, Pelvic pain, Periorbital oedema
Clinical narrative: Mast Cell Activation Syndrome; Postural orthostatic tachycardia syndrome; This literature marketed information has been received from the authors in a published article title as stated below and refers to a 24-year-old female patient. The patient had suffered from Frequent "colds" in infancy. Frequent "Strep infections" in childhood. Menarche at 13 years-old, with immediate dysmenorrhea and menorrhagia. At 17-years-old, frequent "stomachaches and cramping" and waxing/waning diarrhea alternating with constipation. Shortly after starting college, constipation worsened and she started suffering new allergies, episodes of idiopathic urticaria about her trunk and extremities, chronic fatigue, and waxing/waning periorbital edema. At 21-years-old, urticaria worsened, accompanied by throat closing, numbness, and pain. Her reaction allergies was described as throat closing to Amoxicillin (+) clavulanate potassium (AUGMENTIN), throat closing and tongue burning to propranolol and quercetin, throat closing and fever and presyncope and flushing and facial edema to adrenocorticotropic hormone (ACTH, Cosyntropin), and throat closing and tongue burning to generic pyridostigmine tablets. Family history was notable for a paternal grandfather who had had a stroke and fatal lung cancer in his 80s (a few decades after he stopped smoking), a paternal grandmother who had glaucoma, a maternal grandmother who had Alzheimer's disease, heart problem and thyroid problems, macular degeneration, and a corneal detachment, a maternal grandfather who had macular degeneration and diabetes mellitus, a maternal aunt who had a thyroid problem, a paternal aunt who had autoimmune atrophic gastritis, a mother who had a benign thyroid growth with no impact on thyroid function, a father who had hypertension and atrial fibrillation, and a sister who had some allergies. The patient denied any history of smoking, significant alcohol use (beer caused a stomachache, wine caused flushing, and alcohol in general worsened her sinonasal congestion), or illegal substance use.  On an unspecified date, when she was 22 years-old, she received her first dose of unidentified Merck hpv vaccine administered, also reported as Gardasil (Lot #, expiration date, dose, route of administration and anatomical location of vaccine were not reported) for prophylaxis vaccination. Mild facial edema ensued a few hours later and only lasted a few hours, but then she inexplicably lost 10 pounds over the next month. The second Gardasil vaccination was given on schedule a month after the first, and two days later she began feeling very dizzy and nauseous and started vomiting, and she soon was diagnosed with Postural orthostatic tachycardia syndrome (POTS). Chronic sinus congestion worsened and came to include chronic bilateral ear congestion. Throat closing and facial edema began happening more often, especially after ingesting certain foods or medication products or after applying certain facial lotions, which also made her tongue feel burned. Episodes of urinary frequency and urgency and pelvic pain, without evidence of infection, emerged. Episodes of acute dyspnea (she just cannot catch a deep breath) emerged. Other symptoms to emerge included subjective fevers, flushing, feeling cold much of the time, fatigue (often to the point of exhaustion), malaise, headaches, diffusely migratory aching/pain, diffusely migratory pruritus, unprovoked fluctuations in weight and appetite (she had been unable to get back to her normal weight since the Gardasil treatment, plus she reported early satiety), irritation of the eyes, vision problems, tinnitus, epistaxis, easy bruising, sino-nasal congestion, coryza, post-nasal drip, oral canker sores, burning tongue, irritation and numbness of the throat, proximal dysphagia, dyspnea, palpitations, non-anginal occasional chest discomfort/pain, gastroesophageal reflux, nausea, vomiting, diarrhea alternating with constipation, diffusely migratory burning abdominal discomfort including (usually post-prandial) bloating, diffusely migratory weakness (possibly secondary to pyridostigmine, she thought), periorbital and bilateral cheek edema, tingling/numbness (typically about her throat), diffusely migratory adenopathy and adenitis, orthostatic and non-orthostatic presyncope, cognitive dysfunction (particularly memory, concentration, and word-finding), hair loss since about age 17, deterioration of dentition despite good attention to dental hygiene, brittle nails, diffusely migratory rashes (typically patchy macular erythema), hives, insomnia (especially due to feeling hot and dyspneic and due to urinary urgency/frequency), frequent waking, hypersomnolence, and joint hypermobility.  At the time of the initial evaluation, she listed her current medications as pyridostigmine syrup 60 mg thrice daily, levocetirizine 5 mg twice daily, olopatadine 0.6% nasal spray twice daily, and triamcinolone nasal spray 55 mcg twice daily. She sayid grated ginger or turmeric sometimes helped decrease her gastrointestinal problems. Outside records indicate throat swelling to  moxicillina/claviculanic acid and propranolol, faintness, dyspnea, and flushing to ACTH (Cosyntropin), upset stomach to dairy and eggs, and unspecified reactions to cobalt and neomycin on allergy testing. Physical examination at the time of the initial evaluation revealed a trim young woman in no apparent distress, pleasant, cooperative, fully alert and oriented, easily independently ambulatory, presenting with her obviously appropriately concerned/supportive mother. Vitals were notable for a pulse of 87 and a temperature of 99.1F; 24 h urinary N-methylhistamine was at 238 mcg/g  (normal 30200 mcg/g) and Random urinary N-methylhistamine was at  231 mcg/g (normal 30200 mcg/g). On a light scratch test on the upper back, moderately bright dermatographism (erythroderma only, no hives) quickly emerged and was almost fully sustained when last checked 10 minutes later.  Literature report:  Upon internal review the of Mast Cell Activation Syndrome (MCAs) was considered as medically significant.   This is one of several report from the same literature article.   A copy of the published article is attached as further documentation of the patient's experience.