Age: 43.0
Sex: F
Vaccine: FLU3, RUB
Symptoms: Pruritus, Pyrexia, Rash, Skin ulcer, Swelling
Clinical narrative: Information has been received from a physician concerning a 43 year old White female EKG technician with an allergy to betadine who on 11/7/01 was vaccinated with the first dose of rubella virus vaccine live (second generation) (lot # 631088/0183K) in the left deltoid, and influenza virus vaccine (Fluzone) (lot #U0669AA) in the right deltoid. Concomitant therapy included diphenhydramine (Benadryl), vitamins, and estrogens, conjugated (Premarin). The patient had no illness at the time of vaccination and no prior history of reactions to vaccinations. On the evening of 11/7/01 the patient developed fever of 103 degrees F. The patient also developed diffuse itchiness that was reported to be in a symmetrical pattern. The itching involved the axilla region in the upper extremities. The patient noted the onset of a red, well-defined erythematous, raised lesion that had persisted. The area was quite itchy and extremely sensitive to water or any type of irritating substance. Within a few days, the patient also experienced some itching on her chest and legs. She noted some erythema on her left leg that had resolved. The patient had some chest tightness which had also improved. The patient reported no lip or tongue swelling, periorbital edema, or dyspnea. The patient had no coughing. The patient reported that the itching was quite severe and she used diphenhydramine (Benadryl) without relief. The patient was also noted to have malaise and a decreased appetite. There was no nausea or diarrhea. On 11/14/01 the patient was seen by a physician in the occupation health center and upon examination, the patient's vital signs revealed a blood pressure of 106/70 mm/HG, heart rate of 84, respiration rate of 18, and a temperature of 97.9.  The patient's torso showed a large erythematous rash that was raised in both axilla regions. her skin appeared raw and there was no evidence of any type of urticarial type reactions elsewhere. The rash was felt to be contact dermatitis. Inspection of the remainder of the upper extremities and lower extremities showed no other rash-like lesions. It was also reported that the patient had complaints of chills. The patient was placed on therapy with citirizine hydrochloride (Zyrtec), hydroxyzine hydrochloride (Atarax), and was to use cool compresses or burrow compresses to the axilla region and was to use a mild soap and an oil-based moisturizer, and avoid any type of deodorant. On 11/20/01 the patient reported an overall improvement. She had a moderate reduction in the itching and stated that the rash had nearly resolved. The patient noted that there was some dryness at the location and reported that she was using a mild soap and an oil-based moisturizer. She had not resumed the use of deodorant. There was no new rashed at that time. The patient reported diffuse arthralgias which responded to ibuprofen (Motrin) and reported episodes of elevated temperature including 11/19/01. She was continuing therapy with cetirizine hydrochloride (Zyrtec). Inspection of the patient's back showed resolution of all rashes. Inspection of the axilla showed resolution of the red raised lesions and there was some dryness of the skin but no new lesions were noted. Therapy with cetirizine hydrochloride (Zyrtec) was discontinued and the patient was to resume the use of deodorants and use ibuprofen (Motrin) as needed. On 11/27/01, the patient presented to her physician with complaints of arthralgias (from 11/14/01) and myaglias and general malaise. The patient reported that on 11/24/01 she developed diarrhea, and that on 11/26/01 she developed redness along the palmar aspect of both hands along with diffuse arthralgias involving the PIP and MP joints of both hands, more prominent on the left wrist, elbows, knees, and ankles. The symptoms appeared worse on the left than the right. There was also diffuse muscle ache, general malaise, and upper abdominal chest pain. The patient denied chills. The patient's temperature was approximately 101. The patient reported no itching at that time, however reported having bluish discoloration of the left eye with frequent episodes of the eye watering and burning. At that time the patient reported no recurrence of skin rashes. The patient did however report that her hands felt swollen. Inspection of the hands no loss of architecture. Vital signs at that time revealed a temperature of 97.9, respirations of 18, an unlabored pulse of 72. Inspection of the face showed no facial erythema or edema including periorbital edema. There was no discoloration of the eye. Inspection of the oropharynx showed no discoloration, exudates, or erythema. The neck was supple without any adenopathy or JVD and her lungs were clear. Inspection of the back showed no rashes, and inspection of the hand showed a diffuse erythema. There was tenderness to palpitation over the left MP and PIP joints. There was tenderness involving the left wrist and elbow. No crepitus was noted. There was diffuse myalgias invovling the upper extremities and tenderness to palpitation of the abdomen but no rebound or guarding. Examination of the extremities showed no petechiae, edema, or erythema. There was minimal tenderness over the knee and ankle joints. The patient was instructed to resume therapy with cetirizine hydrochloride (Zyrtec), and to continue use with acetaminophen (Tylenol) and ibuprofen (Motrin). On 12/4/01 the patient was seen in the occupational health center concerning her diffuse symmetrical arthralgias involving her hands, upper extremities, and lower extremities. It was reported at that time that her personal physician had placed her on therapy with prednisone on 11/30/01. Laboratory findings from 11/27/01 were reviewed and showed a sedimentation rate of 14, a negative rheumatoid factor, C1, estrace inhibitor 15 normal, ANA negative, and C3 121 and C4 16.8 both considered normal. At the time of the 12/4/01 visit, the patient reported generalized stiffness in the morning upon awakening. She had difficulty getting out of bed but improved with activity. She noted significant pain and stiffness involving her hands with difficulty using her hands for any type of forceful repetitive motion. She stated though that activity decreased the pain. She still had arthralgias involving the elbows, knees, and ankles which was most pronounced after resting. She noted a response to the acetaminphen (+) hydrocodone bitartrate (Lortab) that she had been prescribed. She denied any fever or chills and her swelling had slightly gone down. She reported no other symptoms at that time. Inspection of the patient's hands showed some slight fullness but no loss of architecture. There was tenderness to palpitation over the MP and PIP joint and full range of motion of the knees. The patient was prescribed rofecoxib (Vioxx) 50mg for four days, then 25mg, acetaminophen (+) hydrocodone bitartrate (Lortab) and therapy with prednisone was discontinued. The patient was placed on senna for constipation (incidental finding) that was considered to be secondary to acetaminophen (+) hydrocodone bitartrate (Lortab). On 12/10/01, the patient presented back to the occupational health center at the request of her supervisor due to concerns of functional difficulty. The patient reported no overall change at that time, however she reported that she had recently experienced diffuse arthralgias and myalgias involving the right upper extremity extending from the scapula to the head. She reported having swelling in the hand and she was unable to tightly grip, grasp, or perform any type of fine activity. She also reported having difficulty sleeping at night. The patient was continued on her medication treatment regimen, however, reported some gastrointestinal discomfort. She stated that acetaminophen (+) hydrocodone bitartrate (Lortab) helped the pain but made her goofy. Upon physical examination, the patient was in mild discomfort. She had a flat affect but no guarding. Inspection of the right hand showed slight fullness but no significant loss of architecture. There was tenderness to palpitation along the right scapula and right rotator cuff, right bicep belly, the elbow, the right forearm including the flexor and extensor muscle, the wrist, and the MP and PIP joints. The patient had decreased power grip and hook grip on the right. Therapy with rofecoxib was discontinued and the patient was palced on celecoxib (Celebrex), lansoprazole, tramadol hydrochloride, and tizanidine hydrochloride. The patient was removed from patient care activities and also from motor tasks that required fine or repetitive gripping of the right hand. Occupational therapy with aqua therapy was continued. At the time of this report, the patient had not recovered. Upon internal review, the events of arthralgia and myaglia were considered to be other important medical events. (OMIC) No further information is available.