Age: 4.0
Sex: M
Vaccine: DTAPIPV, FLUN3, MMR, VARCEL, DTAPIPV, FLUN3, MMR, VARCEL
Symptoms: Acute respiratory failure, Base excess decreased, Blood bicarbonate normal, Blood calcium normal, Blood chloride normal
Clinical narrative: A serious spontaneous report of pneumonia has been received from a registered nurse concerning a four-year-old male subsequent to FLUMIST. The patient's medical history included term birth without complications, allergies, acute hyperthermia with anesthesia, eczema and four episodes of wheezing; The patient does not have a history of asthma and he was not exposed to any tobacco. The patient's mother and sister have a history of hypogammaglobulinemia. Vaccinations given on the same day as FLUMIST included DTaP, IPV, MMR and varicella. Vaccinations given within four weeks prior to FLUMIST included hepatitis A and PREVNAR 13. Concomitant medications included fluticasone, cyphroheptadine, desonide and hydrocortisone cream. The patient received one dose of FLUMIST on 23-Aug-2010 for flu prevention. on 28-Aug-2001, the patient started sneezing. On 30-Aug-2010 and 310-Aug-2010, he experienced wheezing, fever 101 to 103 degrees Fahrenheit, runny nose, nasal congestion and decreased appetite. On 01-Sep-2010, the patient began to have difficulty breathing. he was examined by his primary care physician and diagnosed with pneumonia. He was treated in the physician's off with ceftriaxone, levalbuterol nebulizers and oral steroid and went home. The patient's mother continued the medications on 01-Sep-2010. At approximately 3:00 am on 02-Sep-2010, the patient's mother began to note retractions with severe difficulty breathing and brought her son to the emergency room. On examination, his body temperature was 97.9 degrees Fahrenheit, pulse was 172, respiratory rate was 34 and oxygen saturation 83%. Bilateral expiratory and inspiratory wheezes and subcostal retractions were noted. The patient was treated with ceftriaxone, albuterol 10 mg/hr, ipratropium, methylprednisolone and oxygen via a nonrebreather mask and was admitted to the intensive care unit (ICU). Upon admission to the ICU, his body temperature was 98.3 degrees Fahrenheit, blood pressure was 109/71, pulse was 155 and his oxygen saturation was 98% on 7 liters via nonrebreather mask. The medical records noted the patient was "struggling to breath." His white blood cell count was 12.2, hemoglobin was 13.0, hematocrit was 35.9 and platelet count was 293. His sodium was 142, potassium was 4.6, chloride 107, CO2 was 27, blood urea nitrogen (BUN) was 10, creatinine was 0.31 and blood glucose was 125. Venous blood gas showed a pH of 7.33, a pCO2 of 39, a po2 of 158, a bicarbonate of 20 and a base excess of -6. A chest x-ray showed scattered infiltrates on the left and prominent hilar area on the right and developing pneumonia in the left lower lung. Blood cultures were performed. He was treated with ceftriaxone and vancomycin until the blood cultures came back negative. Streptococcal pneumonia antigen and pertussis were both negative. A respiratory viral swab was positiv for H1N1 and oseltamivir was started. The patient began to improve. He was weaned off oxygen, converted to intermittent albuterol and ipratropium and was transferred to a "regular floor." On 04-Sep-2010, the patient was noted to be playful and breathing better. He was discharged from the hospital on oseltamivir, prednisolone and cefdinir. Per the discharge summary, his discharge diagnoses were acute respiratory failure secondary to H1N1 infection, left lower lobe pneumonia likely viral or secondary to pneumococcal pneumonia commonly associated with H1N1 and status asthmaticus. The patient's primary care physician indicated the viral swab was positive for H1N1 due to the patient's recent vaccination with FLUMIST and not due to H1N1 infection. The pneumonia resolved.