Age: 39.0
Sex: M
Vaccine: HEP
Symptoms: Blood immunoglobulin G normal, Blood immunoglobulin M normal, Blood thyroid stimulating hormone normal, Borrelia test negative, C-reactive protein normal
Clinical narrative: The pt reports receiving HepB #3 on 7/5/11 and AVA #7 on 7/6/11 at clinic without adverse event (original history indicated that vaccinations were received on 7/26/11). The pt was in good health at the time of his vaccinations (no URI or abnormal GI complaints; the pt has a hx of IBS with diarrhea). On the evening of 8/16/11 the pt noted a "hive-like" itchy (not painful) rash on his hands, feet (to include palms and soles) and his neck (none in mouth or genital area). The pt had no systemic symptoms (fever, night sweats, joint pain, malaise or cough). The pt denied new foods, medications, hygiene products or sexual contacts; the pt had "worked in his yard that day". The pt was seen on 8/18/11 at clinic. "Annular, target-like erythematous lesions of varying size, up to approx 3 inches in diameter on palmar surfaces, dorsal hands, feet and nape of neck" were noted on exam. He was diagnosed with Erythema Multiforme (EM) and was treated with Valacyclovir, ATARAX and Triamcinolone cream. His symptoms worsened (Increase in the number of lesions spreading up arms and legs symmetrically) so that the pt went to the ER where he was given a RX for BENADRYL and Prednisone with improvement of sx (decrease in pruritus and rash). The pt was seen on 8/19 and the Prednisone was stopped. The pt reports that the rash worsened (increase in number of lesions and increase in pruritus). The pt reports that the Prednisone was restarted on 8/20/11 for 12 days. On the last day of the taper (8/31/11) the rash intensified. Labs "were negative for HSV". Of note, the pt did receive an Influenza vaccination on 9/24/11 with no change to the course of the rash. The pt has been on 2 additional courses of Prednisone (one for 9 days beginning 10/4/11 and one for 12 days beginning 10/17/11) with improvement/resolution of the rash and recurrence of the rash within 1-3 days of steroids completion. The pt was seen by Dermatology on 11/1/11 who thought that the rash was "more of an urticarial reaction than EM". The pt was referred for an appt with an Allergist on 11/11/11. The pt was tested for allergies: positive for Oak, Dermatophagoides Farinae/Pteronyssinus IgE. He also had the following lab studies done: CBC w/diff wnl; CMP wnl; Protein (Total and Electrophoresis) wnl; T4/TSH wnl; Tryptase wnl; Sed Rate/CRP wnl; Histamine release wnl; CH50 wnl; ANA Cascade neg; IgG/A/M wnl; EBV (VCA) IgM neg, EBV (VCA) IgG 4.66H, EBV (EBNA) IgG 4.24H. The pt was prescribed ALLEGRA 180mg qam and ATARAX 25mg qpm. The pt was seen by Ophthalmology on 11/24/11 for severe left eye pain. It was determined that the pt had L>R conjunctivitis and corneal abrasions. The pt was treated with Vancomycin 10mg/ml and VIGAMOX eye drops. When the pt followed up with Dermatology on 2/9/12 he had no evidence of his annular targetoid wheal-like eruptions on his hands or feet. Photos were reviewed and it was thought that the history and photographic evidence suggested an urticarial reaction over EM. The following was ordered: Lyme Ab neg; Borrelia Burgdorferi DNA PCR neg; HSV 1+2 Ab IgG neg; Thyroglobulin Ab Panel neg; throat culture neg. CT of sinuses: No evidence of active paranasal sinus disease. Hepatitis panel, TSH, UA, Ova/Parasites ordered-results not found. As of 2/29/12 pt is having 1-2 lesions occur 1-2 times per week. He is currently taking VIGAMOX eye drops OU qd for improving eye infections and corneal ulcers.