Age: 74.0
Sex: M
Vaccine: PNC13
Symptoms: Injection site erythema, Injection site induration, Injection site pain, Injection site swelling, International normalised ratio normal
Clinical narrative: This is a spontaneous report from a contactable consumer reporting for himself and from a contactable physician. A 74-year-old male patient received PREVNAR 13 (Lot # M06901, Exp. date Mar2017), intramuscular at 0.5 ml, single in the left upper arm on 23Nov2015. Medical history included cholesterol abnormal, coronary artery disease from 2008 and ongoing, hypertension from 2008 and ongoing, hypothyroidism from 2010 and ongoing, vitamin B12 deficiency from 2012 and ongoing, allergies to Penicillins. Concomitant medication included Aspirin, Water pill, SYMBICORT, DUONEB. The patient experienced severe cellulitis of the left upper arm on 24Nov2015 with outcome of recovered, entire left upper arm, swollen, painful on 27Nov2015 with outcome of recovering, malaise/ generally not feeling well on 24Nov2015 with outcome of unknown, loss of appetite on 24Nov2015 with outcome of unknown, some discomfort in left upper arm at injection site on 24Nov2015 with outcome of recovering, reddened area extends from shoulder to antecubital space on 29Nov2015 with outcome of recovering, left upper arm has area that is hard approx. 2' by 1/2' on an unspecified date with outcome of recovering. The patient underwent lab tests and procedures which included on 28Nov2015: Activated partial thromboplastin time (PTT) 24.0 seconds; Alanine aminotransferase (ALT) 21 IU/l; Anion GAP 12 mEq/L; Aspartate aminotransferase (AST) 21 IU/l; Basophil Absolute 0.0 K/uL; Basophil 0.3%; Albumin 3.9 g/dL; Blood alkaline phosphatase (ALKP) 77 IU/l; Bilirubin, Total 0.6 mg/dl; Calcium 9.2 mg/dL; Chloride 99 mmol/L; Creatinine 1.1 mg/dl; Glucose 100 mg/dL; Potassium 4.6 mmol/L; Sodium 138 mmol/L; Urea Nitrogen 17 mg/dl; Carbon dioxide 27 mmol/L; Eosinophil Absolute 0.1 K/uL; Eosinophil 1.3%; Glomerular filtration rate (GFR, Estimated) 69; Haematocrit 39.0%; Hemoglobin 13.6 g/dL; Pulse 64; International normalised ratio (INTL Normalization Ratio) 0.98; Lymphocyte Absolute, 1.4 K/uL; Lymphocyte 14.0%; Mean cell haemoglobin (MCH) 34.4 pg; Mean cell haemoglobin concentration (MCHC) 35.0 g/dL; Mean cell volume (MCV) 98.5 fL; Mean platelet volume (MPV) 8.0 fL; Monocyte Absolute 1.1 K/uL; Monocyte 11.2%; Neutrophil Absolute 7.1 K/uL; Segmented Neutrophil 73.1%; Oxygen saturation (O2 Sat) 97; Platelet count 174 K/uL; Total Protein 7.2 g/dL; Prothrombin Time 12.5 seconds; Red blood cell count (RBC) 3.96 M/uL; Red cell distribution width (RDW) 11.9 cv; respiratory 18; White blood cell count (WBC) 9.7 K/uL. Therapeutic measures were taken as a result of severe cellulitis of the left upper arm, entire left upper arm, swollen, painful, some discomfort in left upper arm at injection site reddened area extends from shoulder to antecubital space, left upper arm has area that is hard approx. 2' by 1/2' included CLEOCIN oral at 300 mg four times daily. Follow-up (22Feb2016): New information obtained from a contactable physician includes: Lot # and expiration date, route, dose, date of administration, anatomical location for PREVNAR 13, medical history, lab data, additional events, treatment onset and outcome.