Age: 28.0
Sex: M
Vaccine: HEP
Symptoms: Swelling, Urticaria, Viral infection
Clinical narrative: This report was received as part of workman's compensation and litigation proceedings. On 1/23/97, the pt sustained a needle puncture injury to his palate while eating. According to a computed tomogram and an otorhino-laryngologist's evaluation, the needle did not pierce the hard palate. Treatment of the injury included flushing the wound with diluted Cepacol mouthwash. On 1/23/97, the pt received Engerix-B and Hep-B immune globulin, tetanus toxoid, and zidovudine (Retrovir). Three days later,on 01/26/1997, he experienced swelling and numbness around the site of injury. The patient took an anti-inflammatory medication and the swelling resolved. Evaluation revealed only unspecified sinusitis, which was judged to be unrelated to the injury. Treatment and outcome of the sinusitis was not provided. On approx. 6/15/97, 144 days, post vax, the pt presented with generalized urticaria. Diagnostic evaluation reportedly revealed elevated serum IgE concentration and excluded a 01-inhibitor deficiency. The pt received unspecified treatment. Intermittent episodes of urticaria persisted and a dx of recurrent benign urticaria was made. The pt is reportedly claiming disability on the basis of the urticaria. CT of the sinuses performed 02/21/1997 demonstrated left sphenoid, bilateral ethmoid, and bilateral maxillary sinusitis. The patient was treated with Augmentin for 2 weeks. The pt was seen by his primary physician on 02/27/1997 complaining of coughing and nasal congestion for 2 weeks, spitting out mucus, and swelling of the right eye. The sinusitis was judged to be unrelated to the injury and resolved. On 06/15/1997, 144 days post-immunization, the pt presented to the ER with swelling of his face and eyes, and numbness of the left side of his face. The ER physician prescribed Ceclor and Entex-LA. The vaccinee was seen by an ENT specialist on 06/16/1997. The specialist prescribed Augmentin. The pt was referred to an allergist. The allergist made a diagnosis of idiopathic induces angioedema. The patient was then symptom free until 09/97, when he experienced swelling that occurred rapidly and involved his throat. He also experienced difficulty breathing. He was taken to the local ER and teated with an injection of epinephrine and given a prescription for a prefilled epinephrine syringe, to use as necessary. The frequency and severity of episodes of hives, facial swelling, and left facial numbness increased and the pt was referred to an allergist. The pt was prescribed Allegra. The episodes of swelling persisted. Allegra was discontinued and replaced with Claritin. This also did not work, so treatment was changed to Zyrtec. Then a combination of Claritin in the AM and Zyrtec in the PM was prescribed. The hives persisted, so Atarax was added to the regimen. The pt was seen by a 2nd allergist on 05/17/1999, again with a flare-up of swelling on his face, probably secondary to a virus infection. The pt had only slight symptoms of respiratory infection. The patient was next seen on 06/01/1999 with marked swelling of his forehead and face. On 06/26/1999 the pt became very dyspneic and had yellow sputum. The pt presented to the allergist on 06/28/1999 with swelling of the face and eyes. The diagnosis was acute bronchitis, asthma, and angioedema of the left side of the face. The pt was treated with antihistamine eye drops, Beclovent inhaler, Albuterol inhaler, and azithromycin. The pt visited the allergist on 04/11/2000 and reported that he continued to experience "outbreaks of swelling which have been becoming more frequent". The allergist noted that the pt had episodes of angioedema of the eyelids. The pt had some wheezing the evening of 04/10/2000. The allergist added Singulair to the other medications the pt was taking. On 05/23/2000 the patient was seen by a 3rd allergist. The pt reported his main concerns to be 'large bulbous swellings throughout his facial area and nowhere else. The pt reported that he developed 4 to 6 episodes of hives per month; he categorized two or three episodes per month as 'severe' and the rest were mild-to-moderate. The hives always occurred only on the head and face. The pt experienced headaches on rare occasions. Upon examination, there was 1cm in diameter macule on the right side of the upper lip. The pt presented to the ER on 07/27/2000 with angioedema of the lip without any other symptoms. He underwent the usual treatments and sent home. He was seen by the 2nd allergist on 07/28/2000. The allergist prescribed prednisone and increased the Allegra dosage. The patient again presented to the ER on 08/24/2000 with right facial and periorbital swelling. His tongue was slightly increased in size but he had no difficulty breathing or swallowing. The pt was treated with Bicillin-LA. The next day he was seen by the 2nd allergist, who prescribed penicillin VK. The patient returned to the ER on 11/28/2000 with itching of his hands, swelling of his hands, facial swelling, and an itchy throat. The pt was seen by a 4th allergist on 03/29/2001. This allergist stated, "the correct diagnosis is angioedema following immunization for Hepatitis B and the use of HBIG in a patient with long standing liver disease. His current medical condition is a reaction to the immunization that he received and his underlying liver disease". The pt is reportedly claiming disability on the basis of the urticaria.