Age: 47.0
Sex: M
Vaccine: TDAP
Symptoms: Angiogram, Anti-SS-A antibody negative, Anti-SS-B antibody negative, Antinuclear antibody negative, Antinuclear antibody positive
Clinical narrative: On 21 MAR 2011, 47 y/o male, who was in his usual state of good health at time of vaccine receipt, received ADACEL vaccine IM in upper right arm. No other vaccines were received on that day. Patient does not recall experiencing significant local reaction at vaccination site. Within 2-3 days post-vaccination, patient noted onset of fever, usually occurring in the evening between 1800 and 2000. Fever preceded by chills/shivering and associated with generalized body aches, head pain, and malaise. Also, on occasion, noted intermittent buzzing sensation in left ear sometimes associated with fevers. Occasionally would feel damp during the night, after the fever broke. Ibuprofen helped fevers and body aches. Initially, symptoms thought to be reaction to Tdap vaccine, but when they persisted for >7 days, patient began taking his temperatures (running between 101 and 102.7) and sought evaluation on 22 APR in Internal Medicine. Fevers noted each evening to every other evening. ROS at that time NEG for sinus symptoms, unexplained weight loss, joint pains, abdominal pain, nausea, cough, shortness of breath, chest pains, palpitations, change in bowels and rashes. EXAM was within normal limits except elevated BP. Labs and CT of Head and chest/abdomen/pelvis were ordered. On 9 MAY 2011, patient evaluated by Infectious Disease (ID). Reported feeling decent during the day, but generally somewhat fatigued with lower exercise tolerance. He had passed a recent PT test, but scored lower than usual. Fevers seemed to be resolving around early May, but resumed by the time of ID appointment and by then, patient had developed a mild, nonproductive cough. By mid-MAY 2011, patient reported hacking cough and mild runny nose. Continued to have fever, chills, and sweats which responded to Ibuprofen. By late-MAY 2011, nonproductive cough continued. ECHO, CXR and EKG were normal. Fevers were not occurring every day, but about 2-4 times per week, and frequency of night sweats was also decreasing. Otolaryngology Evaluation completed on 21 JULY 2011. By this time, cough continuing x 4 months with some throat irritation. Audiogram normal other than bilateral mild symmetric noise notch at 6KHZ. Laryngoscope showed mild cobblestoning of the oropharyngeal mucosa, commonly, non-specific finding of irritation or inflammation often due to reflux or allergies. Treated empirically with NEXIUM 40 mg x 6 weeks and had noted general improvement of cough, with the exception of around time of febrile episodes. A Rheumatology Evaluation was completed in APR 2012. On day of initial consultation, patient's oral temperature was 100.9. Frequency of fever now decreased to about once per week, still ranging between 101 and 102 and accompanied by headache, chills, sweats, and body aches either day before or day of fever. Ibuprofen helps with symptoms and patient notes a profound sweat about 1-2 hours following MOTRIN, and then his fever breaks. Nonproductive cough still continues. Diagnostics included testing for Familial Mediterranean Fever, with results showing heterozygous positive for the E148Q, mutation in the MEFV gene. Patient was started on Colchicine 0.6 mg twice daily in late May. He has not noted a significant change in symptoms at this time. CURRENT STATUS: Continues to experience fevers between 101 and 102 about once per week. Usually the day before onset of fever, patient feels "it coming on" and feels "miserable". He notes mild fever with achiness, headaches (worse with coughing), fatigue, myalgias and cough. When he takes MOTRIN, he usually notes profuse sweating within 1-2 hours and as the MOTRIN is wearing off, his symptoms return. This usually lasts a couple days. History of tick or insect bite around OCT/NOV 2010 with subsequent rash at site, but no systemic symptoms. Treated with antibiotics empirically. Lyme titre Negative. Denies animal exposures, sick contacts, overseas travel or environmental exposures. No history of previous adverse events after vaccines.