Age: 25.0
Sex: M
Vaccine: FLU3, IPV, YF, FLU3, IPV, YF
Symptoms: Hepatic necrosis, Hypotension, Leukocytoclastic vasculitis, Lymphadenopathy, Malaise
Clinical narrative: It was reported that the patient is a 25 year old with no recent history of travel for the past six months, but prior to that has traveled back to Ecuador intermittently and has traveled to Malaysia, Indonesia, Thailand, Singapore, and Japan in the past. The patient was reportedly vaccinated on 04/27/01, with Yellow fever. Concomitantly vaccinated with Fluzone and Poliovax. On 04/29/01, about 48 hours later the patient developed the onset of symptoms of fever, gastrointestinal symptoms and severe weakness. On 05/03/01, the patient called the clinic complaining of fever, severe headache, swollen lymph node in the right axilla, malaise and fatigue. He was instructed to come in to the clinic but declined. On 05/06/01, the patient had progressively become worse and was unable to get out of bed. He eventually called EMS for transport to the ER. In the ER he was found to be hypotensive with a systolic blood pressure of 70, fever 38.7C, diffuse myalgia. Negative for abdominal pain, neck stiffness, headache and photophobia. No focal abnormalities found on the exam. Lab results revealed: Acetaminophen levels 10.9 at 09:38 AM and < 10 by 15:35 PM excluded Tylenol as likely etiology of hepatic necrosis (normal range 10-25 therapeutic). WBC 18.5 with 29 bands; Lymphs 2.6 (Low); Monos 17.5 (High); Platelets 141k (low), UA 28 RBC's, proteinuria with bilirubin and ketones no bacteria or WBC's. BUN/ Creatinine 49 / 7.4; initial LFT's AP 59, AST (SGOT) 436 enzymes peaked; SGOT 436, SGPT 362, bilirubin 1.4, alb 273; ESR 4, amylase normal, CPK22. The patient was started on IV cefuroxime for empiric treatment. During the course of hospitalization form 05/06/01 - 05/25/01, the patient had fulminant illness characterized primarily by acute hepatic necrosis and acute renal failure (requiring dialysis), respiratory failure, severe encephalopathy followed by ARDS. The initial diagnosis included "acetaminophen toxicity" vs "serum sickness-like reaction to vaccine". F/U states on 5/7/01 at 09:00, the pt was found apneic despite previous clear CXR and seen alert and responsive at 08:00. CPR and intubation successfully resuscitated the pt. He was moved to ICU and placed on pressor therapy. All findings consistent with disseminated intravascular coagulation (DIC); the symptoms included thrombocytopenia, anemia, hematuria and proteinuria. The pt received erythropoietin to get HgB over 10. He was seen by an Infectious Disease consultant who evaluated the pt in the ICU for the following impressions: acute renal failure, liver enzyme elevation, s/p respiratory arrest and hypotension, r/o sepsis (SIRS), r/o vaccine reaction given 5 days prior, r/o allergic vasculitis, r/o serum sickness, r/o contaminated vaccine, r/o leptospirosis, r/o post streptococcal disease, r/o antigen-antibiotic complex, r/o Goodpasture's syndrome, probable aspiration syndrome noted at the time of intubation. He recommended: obtaining CXR and cover with broad spectrum antibiotics empirically including single dose vancomycin plus ceftizoxime and clindamycin, send serologies to r/o impressions, review vaccine side effects to see if there are similar syndromes listed. The pt was transferred to a rehab facility from 5/25/01-5/30/01 to recover ambulatory capacity. On 5/30/01 had an outpt visit "recovering liver and renal function". On 6/7/01, the pt returned for prolonged convalescence, expected back in the US in 1/02 to resume studies. It was also reported that this case was originally sent directly to VAERS by a clinic nurse. From F/U correspondence received on 10/22/01, the correct product administered was IPOL, not Poliovax as Poliovax is not distributed in the US. Follow up e-mail correspondence was received on 5/17/02, however there is no new significant information to be reported.