Age: 40.0
Sex: F
Vaccine: RUB
Symptoms: Arthritis, Heart rate increased, Hypokinesia, Joint swelling, Laboratory test abnormal
Clinical narrative: Information has been received from a registered nurse concerning a 39 year old female patient, of average height and weight, with severe arthritic disease (also reported as arthritis all joints (strong family history)), penicillin and latex allergies and a history of two pregnancies who on 1/5/04 was vaccinated IM in the left deltoid with a dose of rubella virus vaccine live (lot # 641025/0279M). Concomitant therapy included methotrexate sodium, leucovorin calcium, promethazine, tizanidine hydrochloride, hydroxychloroquine SO4, acetaminophen (+) propoxyphene napsylate, acetaminophen/hydrocodone bitartrate. There were no other vaccines given at the same time. On 1/18/04 the patient developed a measles rash, low grade fever, and increased arthritic symptoms. Unspecified medical attention was sought. Treatment included diphenhydramine HCl and calamine lotion. The patient had received a dose of methotrexate sodium on 1/4/04 and 1/11/04 but the injection of methotrexate sodium that the patient was scheduled to receive on 1/18/04 was withheld at her physician's advice. Follow up information has been received from a registered nurse in the form of medical records which report that the patient was seen on 1/19/04 by the registered nurse who noted the patient reported a rash which began on 1/18/04. The rash appeared measles-like and was very itchy. It started on the face on 1/18/04 and on 1/19/04 was over most of the body. The patient had no fever to a low grade fever and body aches. Patient was treated with diphenhydramine hydrochloride and calamine lotion. The patient reported she was on methotrexate sodium and another medication per a physician for arthritis and she was to see that physician on 1/20/04. Patient advised to continue same treatment as needed and not to go to work until seen. Patient was seen on 1/20/04 at the rash had improved somewhat. The patient reported that she saw the physician and she was temporarily unable to continue the methotrexate sodium. The patient was taken off of work until at least 1/26/04. She was referred to workman's compensation. On 1/21/04 it was noted that the patient had tested negative for antibodies at hire. It was also noted that rash was more measles-like than rubella like. It was noted that the patient's recent flare of joints could be due to increased reaction to vaccine, or to missing doses of methotrexate sodium. The plan was to consider doing titers now and repeat in three weeks and also get titers prior to resuming methotrexate sodium. The workman's compensation note on 1/26/04 indicated that the nurse called the patient and spoke with patient's husband who reported the patient had not returned to work as she was waiting for medical clearance. The patient's husband reported that the patient complained of losing her grip, and some of the other symptoms she had before the methotrexate sodium, but he assumed it was because she had gone without it. Later on 1/26/04, the nurse reported she spoke with patient and she said pretty much the same thing as her husband. The patient also reported swelling of her knees and ankles. The nurse reported she spoke with a physician who noted that the condition of the patient's immune system was fine for the patient considering her condition, but that it was not the same as a normal person. The patient reported that about four times since she received the vaccine she noticed a brief fast heart rate-once to the point of almost passing out. On 2/4/04, the nurse spoke with patient who reported she was tired and her aches and pains were about the same-feet were the worst. The patient reported she had the flu last week, but was otherwise OK. The patient reported that she might be able to restart her methotrexate soon, which would make her feel better, but she reported she also dreaded it because it made her feel even more tired. On 2/13/04 the nurse spoke with the patient's husband who reported that the physician told the patient she could re-start the methotrexate sodium on 2/15/04, but the patient was not sure if she would because she had been having stomach problems. The husband reported that the patient's legs were still swollen. On 2/16/04 the nurse spoke with the patient who clarified that the stomach problem was that she had been having diarrhea for about three weeks now since this all began. The patient reported she did take her methotrexate sodium on 2/15/04 because her joints were locking up so bad. She reported that she felt more tired (which was typical), but she also had a sore throat and felt achy all over (which was not). The patient reported that her physician had previously told her that she would only develop symptoms like that if her immune system was already low. It was noted that laboratory evaluation revealed: on 12/29/03 the initial Rubella IgG was 1 unit, and Rubella IgM was 0.4 units; on 1/*22/04 (seventeen days after vaccine) there was positive immunity; on 2/5/04 Rubella iGG was 32 units and Rubella IgM was 2.70. It was noted that laboratory results seemed to indicate that the patient probably had some type of residual immune memory that had been boosted indicating that her immune system was OK. On 3/5/04 the nurse reported that the patient said she was doing better, getting energy back, still had more than usual joint pain and swelling in hands, knees, and feet, but improving with each dose of methotrexate sodium. She reported intermittent stomach ache and diarrhea. The patient reported she had been back to work as usual. Additional information has been requested.