Age: 60.0
Sex: F
Vaccine: TD
Symptoms: Dyspnoea, Fatigue, Myalgia, Pain in jaw, Pallor
Clinical narrative: Patient received Td immunization on 6/28/04. One week later, patient complained of pain in her jaw, and inability to fully open her jaw. The patient was admitted to the hospital on 7/16/04 with fever, jaw pain and muscular pain. She was prescribed Valium, Extra Strength Tylenol and Prednisone. The patient is not in the hospital now, date of discharge is not known at this time. The patient has been referred to an ENT specialist. The patient was seen at the doctor's office on 7/20/04, and her symptoms had not resolved. She was still taking Valium as a muscle relaxer, and Extra Strength Tylenol. The patient has another follow up appointment with the doctor on 7/22/04. Note: the patient had started Premarin and Estrogen on the day of Td vaccination - 6/28/04. Follow up information received 7/26/04: An RN at the doctor's office was contacted for follow up information on 7/26/04. The patient did not show up for her appointment on 7/22/04, but has rescheduled for 7/27/04.The patient had received the Td vaccination as a routine booster shot. Follow up information received 7/28/04: RN at doctor's office was contacted for follow up information on 7/28/04. The patient still has muscle aches, but the pain in her jaw is gone. She has no difficulty swallowing and she can now fully open her mouth. The patient has shortness of breath upon exertion and she is very pale and tired. The patient's muscle pain is generalized. The length of hospitalization is still unknown, as the doctor's office does not have the hospital discharge summary at this time. The patient had a consultation with an infectious disease specialist while in the hospital, and the outcome was that the patient did not have an infectious disease. The patient is scheduled to have a treadmill test on 7/30. and she has a follow up appointment with the doctor in two weeks (second week of August 2004). Doctor was contacted on 8/10/04 by the medical director to obtain follow up information. While the patient was hospitalized, she was seen by infectious disease and ENT specialists. The infectious disease consultant considered her symptoms of fever, jaw pain, and muscle pain to possibly be a reaction to the Td vaccine. The ENT specialist did not offer any alternative etiology. The patient has continued to be seen by the doctor for her symptoms, and though her jaw pain has improved and she is able to open her mouth, she continues with joint pain, muscle aches, fatigue and shortness of breath. She has been evaluated by Cardiology and Rheumatology. According to the doctor, her cardiac evaluation was negative. She is still being followed by Rheumatology. The patient's 6/28/04 office visit record was reviewed. On the day of Td immunization (6/28/04), the patient had complaints of knee pain, low back pain, and fatigue. The doctor ordered a ESR, which wa 60 mm/hr (normal is 0-20 mm/hr). A repeat ESR was performed on 7/23/04, and was 100 mm/hr, CRP (C-reactive protein) was 21 mg/dl, and Aldolase was 2.9 U/L. The doctor has not received any other calls of adverse events from patient's in his practice that also received Td-102. The causal relationship of receipt of Td to this AE is not clear. As per medical notes, the patient had complaints of fatiguem knee and back pain and an elevated ESR on the day of Td immunization, suggesting an inflammatory response was ongoing prior to Td vaccination. The patient continues to have elevated acute phase reactants (7/23/04) labs, and evolving symptoms of joint pain, muscle aches, fatigue and shortness of breath. The timing and duration of these symptoms is unusual for a reaction to Td, and a rheumatologic or other inflammatory process is more likely as a cause.  Follow up on 11/04/04 states: "MD's office was contacted on 11/02/04 to obtain follow up information. The pt has recovered from her symptoms of joint pain, muscle aches, fatigue and shortness of breath, and no longer has any complaints. MD has given the pt permission to return to work part-time." 60 Day Follow up information received stated: the pt has recovered from her symptoms of joint pain, muscle aches, fatigue and shortness of breath. The pt's doctor has given the pt permission to go back to work part time.