Age: 15.0
Sex: F
Vaccine: DTAP, HPV4, MNQ
Symptoms: Red blood cells urine positive, Sinus bradycardia, Syncope, Tinnitus, Urinary casts
Clinical narrative: Information has been received from a father concerning his 15 year old daughter with a history of septum deviation who on 07-JUL-2009 was vaccinated with her first dose of GARDASIL. Concomitant therapy included meningococcal vaccine (manufacturer unknown), CLARITIN and diphtheria toxoid (+) pertussis vaccine (manufacturer unknown) (+) tetanus toxoid. The patient's father reported that on 07-JUL-2009 the patient fainted after her first vaccination with GARDASIL. Before fainting, she experienced ringing in her ears, fainted and saw colors. It was also reported that the reporting day, the patient felt dizzy. The patient was taken to the hospital for more testing but was not admitted. On 08-JUL-2009, the patient had recovered. The patient sought for medical attention and contacted the nurse practitioner. Follow-up information was received from a nurse practitioner including medical records indicating that the patient was a 15 year old female, weighing 140 pounds and 64 1/2 inches in height ,with no known pre-existing allergies and a family history of atrial septal aneurysm, who in the morning of 07-JUL-2009 was vaccinated with her first dose of GARDASIL (Lot # 662404/0312Y).Concomitant vaccination included the first dose of MENACTRA (Lot # U2907BA) and the first dose of DAPTACEL. The patient had no illnesses at the time of the vaccination. It was reported that approximately 10 minutes after vaccines, the patient became dizzy and passed out. The next morning the patient  passed out again after waking up and walking to the bathroom, so was sent to the emergency room. The patient reported no loss of consciousness but felt that her legs give out from under her. Prodromal symptoms: dizziness, tinnitus and seeing colors. The patient returned to consciousness rapidly without confusion. Review of systems was done and all of them were found normal. Past medical history did not included seizures, arrhythmia, asthma, COPD or heart disease. The patient did not have known inherited disease, was non-smoker, non drug or alcohol user. Physical examination showed that the patient was alert, awake, comfortable and in no distress. The patient was placed in physician observation status at 8:42 AM for evaluation of syncopal episodes. Orthostatic HR/BP taken (all normal) and patient noted to have significant change in HR with position. Intravenous fluids were started. The patient was initially treated with IV normal saline 2000 ml over 2 hours, observed at bedside, diagnostics reviewed and re-evaluated every 1 to 2 hours. First re-assessment of the patient and ongoing treatment included evaluation of lab data and response to treatment and the patient's symptoms slightly improved. Second re-assessment revealed the patient's symptoms improved. Repeat Orthostatic were then normal. A cardiology follow-up determined to be appropriate as the patient's mother has a history of atrial septal aneurysm and expressed concern for the possibility of an undiagnosed cardiac lesion in the patient. The observation discharge examination revealed the patient's symptoms and physical exam alert and asymptomatic. No murmur was noted. Based on the patient's reassessment and response to treatment, arrangements were made for follow-up with pediatric cardiology. The patient received hydration for volume depletion with normal saline under supervision for 3 hours. The patient was discharged in a stable condition with a diagnosis of syncope. The patient was considered recovered on 08-JUL-2009. Follow up information was received from a physician via medical records which reported that on 24-JUL-2009 the patient was referred to the physician to evaluate her syncope. Two weeks prior to her visit here she received an injection. She felt ringing in her ears and had blurry vision. She then fainted and she did hurt herself in the buttocks. The next day (08-JUL-2009) she was standing at home at 6:15 in the morning putting in contact lenses. She felt ringing in her ears and had blurry vision with dizziness. She was going back to bed and she fell in the doorway. She had syncope for less than 1 minute. Her mother picked her up. She was very very pale but not diaphoretic. A 24 hours dietary recall suggests that she had 67 ounces of fluid, including water and caffeinated diet cola in the 24 hours prior to her visit here. Salt is used in cooking and on the table. She does have some shortness of breath but has had no cyanosis, convulsions or exercise intolerance. Of note she had been tired and swimming poorly at that time. She usually swam18 hours a week since age 12. She has seasonal allergies and does take CLARITIN. She wore contacts for distance vision. She had normal hearing and normal spinal column. The family history is notable for kidney disease in the maternal great aunt. There has been no death at less than age 60 except with accident. There is no history of blood disease. There is a history of hypertension, colon and breast cancer and cardiovascular disease. The patient will be attending junior year of high school. Alone with the patient she is menstruating regularly and recounts no alcohol, cigarette smoking or other drug use. Physical examination was within normal limit. Electrocardiography reveals sinus bradycardia at a rate of 54 with normal axis deviation and normal precordial progression. Echocardiography reveals mild dilatation of the ascending aorta at 3.12 cm. yielding a Z score of 2.26 (Normal Z score is -2 to +2). The remainder of the cardiac anatomy is normal and function is good. Given the orthostatic heart rate changed and blood pressure changed noted above this was likely neurocardiogenic syncope. It was very likely that it was neurocardiogenic syncope because swimmers do lose more salt and fluids than they might otherwise think. The physician had asked that she drink 80 ounces per day of non-water, non-caffeine fluids since caffeine is a diuretic. Best choice would be milk, orange juice with calcium, Gatorade, Propel, ginger ale, Sprite and other decaffeinated beverages, soup, yogurt, pudding, jello, fruit ice, ice cream, large juicy oranges and large slices of melon. She should use salt, soy sauce or ketchup on all the food she is eating so that she retains the fluid she is drinking. The physician would see her again in 1 year's time in follow up of her ascending aortic dilatation. This is most likely simply related to increased cardiac output from bradycardia, but again it would be followed. The patient was allowed activity without restriction. She did not require endocarditis prophylaxis. The physician recommended to send her back if there be continued problems. Additional information is not expected.