Age: 22.0
Sex: M
Vaccine: ANTH, FLU(H1N1), SMALL, TYP, ANTH, FLU(H1N1), SMALL, TYP
Symptoms: Amnesia, Anion gap increased, Antimitochondrial antibody normal, Antinuclear antibody negative, Anxiety
Clinical narrative: This case was received on 09 August 2010 via a QScan search on the VAERS database, under reference number (VAERS ID 386669). A 22 year-old male patient received the following vaccinations on 11 March 2010: ACAM2000 (lot number VV04003A), TYPHIM VI (lot number D04121), anthrax (manufacturer Emergent, lot number FAV226), and H1N1 vaccine (manufacturer Novartis, lot number 104045P1). On 18 March 2010, seven days post-vaccination, the patient participated in a prolonged high intensity exercise field run wearing about 30-40 pounds of gear for greater than one hour. At the end of the four mile run, he felt "unwell" and walked around for approximately 1 1/2 laps and then collapsed. The patient reported that prior to the run he felt "near 100%" and was well hydrated. The patient was transported by ambulance to the emergency room (ER) and when transported, he was noted to have an altered mental status. He was initially unresponsive, and then agitated and combative. His temperature was 109 degrees Fahrenheit (rectally), which was confirmed at the ER as being greater than 107 degrees Fahrenheit (rectally). In an effort to cool and sedate him, he was intubated and administered ATIVAN and HALDOL. On 18 March 2010, emergency room laboratory findings revealed anion gap acidosis (AG 19) with bicarbonate of 18; NA+ 142, cl- 105, BUN 16, CA++ 10.9, Albumin 4.3, AST 45, ALT 36, CPK 478, Troponin 0.11, and Creatinine 2.1. His temperature went down to 103 degrees Fahrenheit and he was transferred to another hospital. Upon transfer, CPJ was 7000 and a urine drug screen was negative. Upon admission, his temperature was down to 101 degrees Fahrenheit and he was given additional FENTANYL and VERSED due to agitation. He was hemodynamically stable with heart rates of 80-90, systolic blood pressure 100-20s; and oxygen saturation >97%. He was also noted to have had loose green stools. During his course of hospitalization, he had been agitated and febrile to 102 degrees Fahrenheit (rectally) despite corrective treatments with a cooling blanket, fan, and ice packs. He was administered LIBRIUM due to concern for seizures (DTs) considering his alcohol intake of about 30 beers per week; his last alcohol ingestion was around 14 March 2010. VERSED was administered as needed for agitation. He had a CT performed and while in the scanner, he became unresponsive with sluggish small pupils, his heart rate was in the 30s and he required resuscitation. There was concern for cerebral edema with concern for herniation (per CT). He was transferred to medical ICU, MARNITOL was administered with improvement noted. A follow-up MRI was performed and revealed no evidence of elevated intracranial pressure (ICP). DOXYCYCLINE, VANCOMYCIN, CEFTRIAXONE, and ACYCLOVIR were administered as coverage for infections. Following consultation with CDC and Vaccine Healthcare Centers, he received varicella immunoglobulin (VIG) 6000 units per kg (x1) and methylprednisolone intravenously. During the course of hospitalization, his temperature returned to normal after several days, his liver function tests improved, and his mental status improved to near baseline. By 24 March 2010, the patient was extubated and he was able to follow-commands and answer questions. He had no recall of the previous seven days and was unable to recall any events following his collapse until about 8 days later while hospitalized. On 28 March 2010, he was discharged. On 13 April 2010, he was evaluated in follow-up at which time it was noted he had problems with motor skills (described as difficulty using a fork and pen) and continued to report memory lapse. At the time of the report, the patient had not recovered. Of note, additional adverse events were coded by VAERS which included anxiety, resuscitation. Epstein-Barr virus test positive, initial insomnia, infection, mood swings, and intracranial pressure increased. Additional diagnostic lab codes entered by VAERS included: Alanine Aminotransferase Increased, Alpha-1 Anti-Trypsin Normal, Amnesia, Anion Gap Increased, Antimitochondrial Antibody Normal, Antinuclear Antibody Negative, Aspartate Aminotransferase Increased, Bacterial Test Negative, Bilirubin Conjugated, Blood Albumin Normal, Blood Bicarbonate Decreased, Blood Bicarbonate Normal, Blood Bilirubin Normal, Blood Calcium Increased, Blood Chloride Normal, Blood HIV RNA Below Assay Limit, Blood Immune Globulin G normal, Blood Sodium Normal, Epstein-Barr Virus Test Positive, Gamma-glutamyltransferase Increased, Blood sodium normal, Laboratory Test, Polymerase chain reaction, Serum ferritin increased, Troponin, Computerised tomogram abnormal, HIV Test Negative, Troponin, Ehrlichia test, Blood Immunoglobulin A Normal, Blood Thyroid Stimulating Hormone Decreased, Smooth Muscle Antibody, Blood Immunoglobulin E, Blood urea normal, Complement factor C3 Decreased, Cytomegalovirus test negative, Free thyroxine index normal, Hepatitis B surface antigen negative, Chest X-ray abnormal, Urine culture negative, Echocardiogram abnormal, Hepatitis A antibody negative, Lumbar puncture normal, Protein total normal, Ultrasound scan abnormal, Red blood cell sedimentation rate normal, Streptococcus test negative, Blood creatine phosphokinase increased, Blood creatinine increased, Endotracheal Intubation, Hepatitis C test negative, Intracranial pressure increased, Platelet count decreased, Rheumatoid factor negative, CSF test normal, Culture throat negative, Echocardiogram, Herpes simplex serology negative, Blood immunoglobulin M decreased, C-reactive protein increased, Blood culture negative, Brain scan normal, Complement factor C4 decreased, Electroencephalogram abnormal, Hepatitis B test negative, International normalised ratio increased and Nuclear magnetic resonance imaging brain normal. 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