Age: 36.0
Sex: M
Vaccine: FLU3, HEP, IPV, MMR, MNQ, TD
Symptoms: Liver function test normal, Lymphocyte count normal, Malaise, Metabolic function test normal, Monocyte count increased
Clinical narrative: 42 y/o (was age 36 at time of reaction) M, who works in blood donor center, who reports history of hypersensitivity vasculitis post-receipt of Hepatitis B vaccine on 13 MAR 2007. 30 MAR 2007, Initial Evaluation for rash: HPI -rash x3-4 days began on thighs and spread down legs and up trunk to hands. Nonpruritic, subj fevers, swelling & pain to bilat knees, swelling in hands & wrists. Joints hurt 3/5 (0-5), red spots all over hands; legs are difficult to move. SOB; cough x 2 weeks, red dots x 5 days, leg pain since last night. O: multi-joint pain, petechial rash to lower extremities, hot swollen knee joints, constant x 5 days. EXAM: T 98.3, 123/84, 84, 16. Skin - red papules on LE, confluent, some with central black centers, spares trunk, arms, face. IMP: rash c/w hypersensitivity reaction, not c/w sepsis, meningitis, gonococcal. F/U for repeat labs and eval. 3 APR 2007, MC, Dr.: HPI: Seen in consultation for vasculitis. Noted red spots on his legs and thighs on Thursday of last week. Since then, he has had swelling in his extremities, with pain in the areas of swelling. Went to ER on 30 MAR when the pain in his legs prevented him from walking. Diagnosed with vasculitis. States his lesions on his legs are healing, but he has noticed new lesions on his arms and torso. Tenderness at the site of the lesions, without itching. Has been sick (URI/sinusitis symptoms) for about two weeks. Felt chills/sweats but has never had a fever on eval. No dysuria or hematuria. No blood in stools. No previous hx of easy bruising. No neck stiffness. BCs negative. Has not been on any meds except cough drops recently. EXAM: Normal except skin: palpable purpura on legs, buttocks, thighs, and torso. A/P: Hypersensitivity vasculitis: Unclear triggering factor, though likely infection. Usually self-limiting, but will provide antihistamine for itching and course of systemic steroids. Sinusitis: symptoms present over 2 weeks, so will proceed with antibiotics. 9 JUL 2009, Rheumatology, MC, Dr. HPI: Musculoskeletal symptoms - Typically lower extremity pain from knees down during an attack. No localized joint stiffness worse in the a.m. Subsequent to a number of vaccinations and possibly a URI, he developed acute "necrotizing" lesions of the legs, with edema and widespread joint pain, along with more widespread petechiae. He was treated with oral corticosteroids on the presumptive diagnosis of hypersensitivity (leukocytoclastic) vasculitis, and the lesions/swelling resolved in about 3-4 days, with resolution of pain in about 2 weeks. He had a brief recurrence some 8 weeks later, again responsive to steroids. A few weeks ago, while training, he had a recurrence of LE pain with a few petechiae of the upper and lower extremities, and was treated with ibuprofen. He is leaving in September of this year, and opinion is sought on origin and need for prev treatment. ROS: essentially negative. EXAM: Negative. Skin: No petechiae, vasculitic lesions, purpura or nodules. No EN to the lower extremities. Scars c/w history. Two professional tattoos, left shoulder and left ankle, two nonprofessional tattoos, left chest and left 4th finger. No plaques were seen. Showed no subcutaneous nodules. No palpable purpura was seen. No livedo reticularis. A/P: HYPERSENSITIVITY VASCULITIS: certainly a possibility, with a reactive arthritis, although no workup has been done. Marginal ESR and CRP elevations are seen surrounding an attack, but there is no other serologic evidence of serious disease. Marginal elevation of ANA seems unrelated, but should not be completely discounted. No evidence of EN or hilar/mediastinal involvement to suggest sarcoid. ANCA positivity is associated with leukocytoclastic vasculitis, among other things, and this will be checked. The lack of finger or toe acrocyanosis and Hep C negativity speak against chronic viral origin, and there is no evidence of RA or Sjorgren's.