Age: 1.01
Sex: F
Vaccine: HIBV, MMRV, PNC
Symptoms: Red blood cell sedimentation rate increased, Restlessness, Screaming, Vomiting
Clinical narrative: DATE OF ADMISSION:    07/15/2006                                                                                                              DATE OF DISCHARGE:    07/19/2006                                                                                                                                                                                     HISTORY OF PRESENT ILLNESS:                                            This is a 12-month-old female without a significant past medical       history who presented on 07/15/2006 with onset of fever for two days   after receiving the measles, mumps, and rubella vaccine on June 29,     2006.  The patient developed a febrile illness lasting seven to ten     days after the vaccine.  On July 12, 2006, the parents noted that the   patient's behavior was changed from baseline.  The patient was          screaming inconsolably, restless, and this behavior would fluctuate     with periods of somnolence when the patient was arousable by            excessively sleepy.                                                                                                                         Additional history was notable for a dog bite on the cheek one month    prior to the admission. The dog is a family pet, with no vaccination   status, is alive, and appears healthy. Given the amount of edema observed on CT and LP was deferred, and the patient was started on multiple broad spectrum antibiotics such as     cefotaxime, vancomycin, Zithromax, and was started on acyclovir, as   well.   Given the history of vaccination with varicella vaccine, it    was initially felt that this was the probable etiology of the          patient's presentation.  The possible etiology of a dog bite was       thought to be a less likely etiology for the patient's symptoms.  The patient was then transferred for further workup,      including an MRI of the brain.                                       HOSPITAL COURSE:                                                     1.  FLUIDS, ELECTROLYTES, AND NUTRITION:  The patient was tolerating clears without difficulty and was placed on IV fluids of D5 1/4 norm saline with 10 mEq of KCl at 35 ml per hour.  On hospital day two,   July 10, 2006, the IV fluids were decreased to 17 ml per hour.  The  electrolytes on admission were within normal limits.  Also on hospital day two, the patient was started on Zantac 6 mg IV q. 8 hours for    prophylaxis during use of steroids.  On hospital day four, July 18,  2006, the patient's IV was discontinued, as the patient was         tolerating a regular diet.                                             2.  CARDIOVASCULAR:  The patient had no signs of respiratory            compromise and appeared hemodynamically stable throughout her           admission.                                                                                                                                      3.  INFECTIOUS DISEASE:  The patient was initially continued on         antibiotics and antiviral coverage as initiated.  On  hospital day one, July 17, 2006, the patient's antibiotics were         discontinued, as she remained afebrile, and infectious etiology was    not suspected.  Acyclovir was also discontinued on this day.                                                                                                                                                                                                                                                       RE-ADMISSION  Date of admission: 07/23/2006                                                                                               Time: 07:35 p.m.                                                                                                            Chief complaint: 13-month-old female infant with    Vomiting and associated intermittent lethargy. Historian:    Patient's father. History taken in room 17 in the Emergency   Department.                                                                                                                History: this 13-month-old female infant was brought to the emergency room by her father because of concern for emesis, 4 episodes since this morning, without diarrhea, with minimal low-grade fever about 99 degrees Fahrenheit, but with intermittent episodes of somnolence. According to the father, the baby is showing similar signs and symptoms which she displayed about 8 days ago, on July 15th, when she was evaluated by the neurologist and the pediatrician. At that time the diagnosis was possible vaccine- associated  encephalomyelitis.                 Infant was transferred to the pediatric intensive care unit for special MRI study. Results so far still not available. Discussion was held  With pediatric neurologist who recommended that the patient be admitted and observed overnight. He will reassess the patient some time Monday, July 24th and by that time he will have obtained and reviewed the result of the MRI study done. This patient is currently on zantac liquid as well as prednisone, being used to treat the infant for the diagnosis of  possible vaccine-related encephalomyelitis possibly associated    with measles-mumps-rubella/varicella component. Infant has not had any seizure activity, has not shown any irritability, and even though appetite has decreased some, father claims that child has not had any diarrhea except for the 4 episodes of emesis. 7/25/06-Reported submitted H&P and DC summary for this patient's confinements.  DATE OF ADMISSION: 07/15/2006 DATE OF DISCHARGE: 07/19/2006 HISTORY OF PRESENT ILLNESS: This is a 12-month-old female without a significant past medical history who presented on 07/15/2006 with onset of fever for two days after receiving the measles, mumps, and rubella vaccine on June 29, 2006. The patient developed a febrile illness lasting seven to ten days after the vaccine. On July 12, 2006, the parents noted that the patient's behavior was changed from baseline. The patient was screaming inconsolably, restless, and this behavior would fluctuate with periods of somnolence when the patient was arousable by excessively sleepy. Additional history was notable for a dog bite on the cheek one month prior to the admission. The dog is a family pet, with no vaccination status, is alive, and appears healthy. Given the amount of edema observed on CT and LP was deferred, and the patient was started on multiple broad spectrum antibiotics such as cefotaxime, vancomycin, Zithromax, and was started on acyclovir, as well. Given the history of vaccination with varicella vaccine, it was initially felt that this was the probable etiology of the patient's presentation. The possible etiology of a dog bite was thought to be a less likely etiology for the patient's symptoms. The patient was then transferred for further workup, including an MRI of the brain. HOSPITAL COURSE: 1. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was tolerating clears without difficulty and was placed on IV fluids of D5 1/4 norm saline with 10 mEq of KCl at 35 ml per hour. On hospital day two, July 10, 2006, the IV fluids were decreased to 17 ml per hour. The electrolytes on admission were within normal limits. Also on hospital day two, the patient was started on Zantac 6 mg IV q. 8 hours for prophylaxis during use of steroids. On hospital day four, July 18, 2006, the patient's IV was discontinued, as the patient was tolerating a regular diet. 2. CARDIOVASCULAR: The patient had no signs of respiratory compromise and appeared hemodynamically stable throughout her admission. 3. INFECTIOUS DISEASE: The patient was initially continued on antibiotics and antiviral coverage as initiated. On hospital day one, July 17, 2006, the patient's antibiotics were discontinued, as she remained afebrile, and infectious etiology was not suspected. Acyclovir was also discontinued on this day. RE-ADMISSION Date of admission: 07/23/2006 Time: 07:35 p.m. Chief complaint: 13-month-old female infant with Vomiting and associated intermittent lethargy. Historian: Patient's father. History taken in room 17 in the Emergency Department. History: this 13-month-old female infant was brought to the emergency room by her father because of concern for emesis, 4 episodes since this morning, without diarrhea, with minimal low-grade fever about 99 degrees Fahrenheit, but with intermittent episodes of somnolence. According to the father, the baby is showing similar signs and symptoms which she displayed about 8 days ago, on July 15th, when she was evaluated by the neurologist and the pediatrician. At that time the diagnosis was possible vaccine- associated encephalomyelitis. Infant was transferred to the pediatric intensive care unit for special MRI study. Results so far still not available. Discussion was held With pediatric neurologist who recommended that the patient be admitted and observed overnight. He will reassess the patient some time Monday, July 24th and by that time he will have obtained and reviewed the result of the MRI study done. This patient is currently on Zantac liquid as well as prednisone, being used to treat the infant for the diagnosis of possible vaccine-related encephalomyelitis possibly associated with measles-mumps-rubella/varicella component. Infant has not had any seizure activity, has not shown any irritability, and even though appetite has decreased some, father claims that child has not had any diarrhea except for the 4 episodes of emesis. According to submitted information, an MRI study by pediatric neurologist was scheduled for 7/24/06. Will request results of study.  7/25/06-MRI report requested from two Dr.'s.