Age: 35.0
Sex: F
Vaccine: PPV
Symptoms: Pyrexia, White blood cell count increased
Clinical narrative: Patient came to the emergency room having had a PNEUMOVAX vaccine in the upper left deltoid and she complained of pain two-and-a-half days later, swelling distal to the injection site in the lower biceps area.  This was erythematous associated with severe pain.  A CAT scan done in the emergency room revealed edema in the underlying muscle and fat.  The emergency room physician talked with infectious disease specialist at the medical center and they had one recent similar episode in a patient with a white count of 20,000.  Patient's white count was 9000 and clindamycin and vancomycin were started immediately.  She had complaints of fever, chills, generalized aching, and malaise.  Hospitalized 3/13/08 - 3/16/08 for IV antibiotics.  Patient wears glasses.  She has no known chest problem.  Occasionally has wheezes, has a heart murmur since the child, and a little GI distress since she has been taking the Ibuprofen for her knee problem.  No frequency, smell of the urine of dysuria.  She had one child by cesarean section.  Her last menstrual period was two weeks prior to admission.  On exam on discharge, she is well.  Has improvement in her vital signs.  No fever.  Her white count was 4000 with no left shift.  Sclerae are white.  She has pink moist mucous membranes.  The area of erythema on the left upper arm, which began as deeply erythematous, very tender, and untouchable is now pale with a very slight pink rose color in a quarter size area anterior mid biceps on the left side.  The erythema is marked on her left arm from a cauliflower shape over the very distal deltoid proximal or mid biceps area.  Yesterday, it was erythematous almost in a band halfway around the arm and today it is almost normal skin, which is dramatically changed.  She has no streaks.  No other areas of problems on the skin.  The patient has no adenopathy in either axilla in the neck.  She has no wheezing in her chest.  Her abdomen is normal.  The patient was admitted to the floor, had an IV placed.  The area of erythema by 03/14/08 had enlarged.  The pain was decreased and it was seemed to be more superficial.  She still had a low-grade temperature by the next day, 03/15/08, by the evening she had no fever, and by the next day she had no fever.  It was more superficial.  Her white count yesterday was 5500 and she was maintained on the Vancocin and Cleocin for 24 more hours, which made a lot of difference.  Her white count is now 4000 and hematocrit 32.9.  Her vancomycin level has maintained normal level in the mid 8 to 9.  She had no growth on her blood cultures at 48 hours.  Her vancomycin peak was 15.9, which is in the lower range of normal.  She will continue on Cleocin 300 mg q.i.d. for the next seven days.  She will follow up with the doctor on Wednesday.  She will make her own appointment.  She can put hot pack and use Sama, an over-the-counter product for itching as needed.  She will return to her normal diet and activities as she gets stronger over the next week.  Her medications on discharge are the same as on admission except added is Cleocin 300 q.i.d. and probiotics to be taken at a different time from the medication.  6/12/08-records received for DOS 03/13-03/16/08-Presented to ED 2 1/2 days after vaccination, with swelling distal to injection site in lower biceps area, erythematous assoicated with severe pain. Low grade fever.