Age: 43.0
Sex: F
Vaccine: FLU3, PPV, TDAP
Symptoms: Alanine aminotransferase normal, Anion gap decreased, Aspartate aminotransferase normal, Band neutrophil count, Basophil percentage decreased
Clinical narrative: 43 y/o F received BOOSTRIX vaccine in her RUE. She denies any significant local reaction at this site. She also received the PNEUMOVAX and AFLURIA vaccines the same day, in her LUE. She received her vaccines around 1330-1400. After supper that pm, she felt feverish and had a pounding headache on the top of her head that she rated at a pain intensity level of 9-10/10 using a pain scale of 0 (= no pain) to 10 (=worst pain ever experienced). She describes this headache as a "pneumonia" headache (similar to others she has had when diagnosed with pneumonia). She self treated with MOTRIN 800 mg with some decrease in pain. She went to bed & awoke around 0130-0200 with chills. Her teeth were chattering, she was shaking, & "never felt so cold". She covered up with more blankets & went back to sleep. When she awoke on 27 OCT, she felt hot & her linens and night clothes were soaked with perspiration. She also reports continued headache, fatigue, aching, & lethargy. Throughout the weekend, she stayed in bed and rested. She continued to experience chills alternating with sweats & fever. No nasal congestion, post-nasal drainage, or cough. She checked her temperature throughout the week-end and reports temperatures ranging between 98 to 102 degrees F, with highest temperature reading of 102.8 degrees F. She continued to self treat with MOTRIN. On 28 OCT, she used a space heater with multiple blankets to stay warm but she was still shivering. Also on Sunday, pt noted some tenderness & a pink area (not at vaccination sites) on her mid-anterior left upper arm, with irregular borders, approximately 4"x3". She denies N/V/D or anorexia. While she did eat during the weekend, she did not push fluids. She denies respiratory symptoms or hives. On 29 OCT, after 72 hours of symptoms, pt's husband noted a significantly reddened area on her left upper arm, between her left anterior shoulder & her elbow. Monday afternoon pt sought evaluation in the ER. In the ER, pt's heart rate was 137 bpm & her temp was elevated. She c/o malaise, fever/chills/sweats, headache (6/10) & LUE and redness (see photo - 29 OCT). She received 2 liters of IV fluids, 1 dose of MOTRIN, & later, a dose of TYLENOL during the 5-6 hours she was in the ER. She had a normal CXR, but her WBC was elevated to 20.4 with elevated neutrophils and decreased lymphocytes. By the time she was released from the ER, she reports she was starting to feel better. She was instructed to alternate MOTRIN & TYLENOL and follow up with her PCM. The following day, 30 OCT, pt continued to experience headaches, fatigue, generalized aching, as well as redness, warmth & pain of LUE. The chills and shivering had resolved, & her sweats occurred only during the course of the night. She noted some improvement following medications & she also applied ice to her left upper arm. She followed up with her PCM on 31 OCT. At that time, she was afebrile. She had treated her headache that morning with MOTRIN followed by TYLENOL within 2 hours, & by the time she arrived in the clinic, her headache was gone. She noted an increase in her energy level & her body aches had almost completely dissipated. Her LUE was still red, sore, warm & swollen (see photo - 31 OCT). Since then, her primary complaint is ongoing tenderness, swelling, warmth & some redness of her LUE, as well as continued night sweats. She has resumed light housework & ADLS. Pt was feeling fine prior to vaccine receipt & denies a history of recent infection or viral symptoms. No recent trauma or bites to LUE. She denies prior vaccine reactions, except following receipt of the flu vaccine in OCT 2010. Reports she received the flu vaccine after having a viral illness x1 week. Within 3-4 days of receiving the flu vaccine, she experienced lethargy, fever, chills, body aches & headache, as well as chest tightness and a productive cough. She was evaluated & dx'd with pneumonia, & she was treated with antibiotics IM, as well as prescribed a Z-pack.