Age: 56.0
Sex: M
Vaccine: ANTH, HEPAB, TDAP, TYP
Symptoms: Anti-SS-A antibody negative, Anti-SS-B antibody negative, Anti-cyclic citrullinated peptide antibody positive, Antinuclear antibody, Antinuclear antibody negative
Clinical narrative: Case Manager calls staff at HC re 57 y/o w/ onset of symmetrical polyarticular joint pain in mid-June of 2011, following receipt of multiple immunizations required in mid-April 2011. Specifically, the patient received AVA #4, Adult Hep A-Hep B, Td, Typhoid ViCPs (inactivated vaccines) on 16APR11, in addition to Varicella Vaccine (live virus) on 18APR11. The patient endorses his onset of symmetrical, polyarticular pain in his hands and shoulders while sitting in class on 16 JUN 11. (See Note 15 SEP 11, Provider). The patient denies a history of adverse reactions to prior immunizations, including the annual seasonal influenza vaccine. He denies any viral or GI illness in the 30 days prior to receipt of the above mentioned vaccines. PMH is significant for: 1. surgical repair of his rt rotator cuff (JAN 2005), s/p injury to rt shoulder due to fall from truck; 2. arthroscopic repair of ACL and meniscal tears of his rt knee (FEB 2005) s/p twisting his knee while running in JUN 2004; 3. pneumonia (04 JUN 2011); 4. HTN; 5. Hyperlipidemia- takes VYTORIN 10/20. The patient endorses a + FH of auto-immune disease. His only sister died from complications of severe RA when she was in her 50's. He was seen on 02 AUG 2011 in Clinic for c/o "joint pain/swelling in several locations x 3 weeks" w/ limited ROM and tenderness to palpation of joints in hands. Diff Dx was "Over Use / Strep Arthritis." In SEP 2011, patient was seen for c/o "joint swelling fingers and severe pain of "8"/10 and Provider noted "pt will need to be screened for auto-immune disease"...will treat now for possible inflammatory condition like seronegative spondyloarthropathy." On 08-15th SEP 2011, patient presented to the Clinic with bilat symmetrical joint pain in wrist, elbows, shoulders, knees, ankles and minor joints of hands and feet >>> Provider noted: "will inquire if auto-immune testing can be done." On 20SEP2011, patient presented to Clinic, taking INDOCIN with some reported relief. Also having problems with HTN and elevated uric acid >>> Provider noted: "should see Rheumatology when he can." On 06OCT11, seen again at Clinic and Provider noted: "suspect RA- pain worse in AM and gets better at night. +RF, + FH RA >>> Stop INDOCIN and ZANTAC. Start CELEBREX and progress to minimal rx for pain control. Start TOPROL nightly." Medevac back on 22NOV11. (See Note, PCM). Patient was lost to f/u when he transferred. HC NP reestablished contact with patient at end of NOV/DEC 2012. (17JAN13) NP and Dr. conducted TC with the 58 y/o male, who is currently in another location. (See VHC Summary Note). Patient has been followed by RHEUM since JAN 2012. Dx of RA was confirmed. Currently taking ORENCIA w/ decreased swelling of joints. Patient saw his Rheumatologist yesterday (16 JAN 13). Added MOBIC for pain. Mobility is still good. Still able to function on own. His is being kept until they can determine the best regimen of Rx for him. He has not received any further doses of the AVA or of any other vaccines, w/ exception of his annual seasonal influenza imm, which we strongly reinforce, as patient is on immuno-modulating medications for his RA. It had been 3 months since his last flare, when they started him on ORENCIA. Prior to that he took HUMIRA, which helped for a time and then his sx came back "with vengeance." A and P: Vaccine Causality Assessment: 58 y/o male with confirmed dx of RA and +RF, being followed by Rheumatology, requests vaccine causality evaluation (See HPI). A and P: WHO AEFI Causality Category Unlikely: A clinical event whose time relationship to vaccine administration makes a causal connection improbable, but which could be plausibly explained by underlying disease or other drugs or chemicals). Dx RA confirmed. 1. Patient has a clear genetic predisposition / + Family Hx RA- his sister died from complications of RA in her 50's. 2. Patient also has hx of traumatic joint injury to rt shoulder and rt knee which occurred. (See HPI). 3. A 45-day cut off is generally accepted by most immunologists and experts in vaccinology for the temporal association of vaccines to the onset of sx. The patient's onset of joint swelling and pain was on 16 JUN 11, approximately 60 days s/p his receipt of multiple vaccines. 4. The determination of the patient's receipt of the vaccines in question is supported as clearly being administered. 5. The case for multiple immunizations triggering latent auto-immune disease has been raised, questioned and continues to be studied, but at present the medical literature does not support a causal relationship between vaccines and chronic inflammatory RA or other auto-immune dz. 6. HC does not recommend patient's receipt of additional doses of AVA, which will not be necessary. 7. VHC recommends that all future vaccines be given individually to more accurately monitor adverse reactions. 8. HC strongly reinforces the patient's yearly receipt of the seasonal influenza vaccine, as he is on immuno-modulating medications, which put him at increased risk for influenza disease. 9. Dr. was consulted on this case and is in agreement. Thank you for your consultation. 2. Rheumatoid Arthritis: Dx RA by Rheumatology. +RF. Currently taking ORENCIA and MOBIC as adjunct for pain. Follow up: with PCM. - Comments: HC defers to Rheumatology, PCM, and facility for medical management of pt's condition. Thank you for your consultation to our service regarding vaccine causality. Discussed: Diagnosis, Medication(s)/Treatment(s), Alternatives, Potential Side Effects with Patient who indicated understanding. (Not AEFI). Auto-Immune chronic condition (RA).