Age: 44.0
Sex: F
Vaccine: SMALL, SMALL
Symptoms: Confusional state, Headache, Injection site ulcer, Migraine, Neuralgia
Clinical narrative: Nervous system  central & peripheral:  [1] Incapacitating headache starting abruptly 12:57 am 3/6/03.  Vascular & non-vascular components with quality & severity of HA vastly different from "usual" migraines.  8/10 on pain scale. Vascular component diminished by afternoon with maximal use of Midrin & acetominophen.  HA persisted through 3/7/03. Both days: mind "muddled," unable to hold conversation with housemate, needed assistance with meals, confined to bed.  [2] Left side sciatica started in morning 3/1/03, maximal in evening, 3/10 on pain scale, reaching below knee. Persisted through 3/2/03 then intermittent through 3/25/03, 1/10 on pain scale, limited to thigh area. Sciatica not related to position or movement, no associated musculoskeletal pain or weakness. Sciatica not experienced since 1987. L4-5 laminotomy 1985 after traumatic herniation 1984.  [3]Bilateral ulnar nerve hypersensitivity starting in morning 3/1/03 (onset coincidental with sciatica). Bilateral ulnar nerve sensitivity noted through 3/31/03, left ulnar nerve sensitivity until 4/19/03.  Waxing & waning of sensitivity noted, but not assessed daily (self-percussion).  Cushioned elbows with pillows for sleeping. Neurologist examination 3/14/03: Tinel's at left ulnar sulcus otherwise normal exam. No history of ulnar nerve sensitivity.  [4] Left arm paresthesias starting 10:00 am 2/26/03 persisting intermittently until present (5/1/03). Initially occurred in left hand, swelling around wristwatch band noted with conspicuous depression after removing watch. Repeated episodes of paresthesias affecting left hand in glove pattern to mid-lower arm. During first few weeks it was difficult to separate symptoms of ulnar hypersensitivity from paresthesias. Paresthesias noted to occur after sitting/working at a desk/computer for a short while. Conjectured to be due to localized dependent edema.   Cardiac/circulatory: [1] Left arm edema, see above.  [2] Dependent ankle edema: Noted some time in first week post-vaccination, attributed to excess salt in diet, treated with 12.5 mg HCTZ and dietary control of salt. Occasional bilateral 1-2+ ankle edema in weeks 2-3, treated with HCTZ prn. In week 4 started HCTZ routinely qd. In week 5 cardiac risk information disseminated, HCTZ increased to bid. Cardiac work-up normal. Decreased HCTZ to qd after normal echocardiogram (4/23/03), returned to bid after noting increase in left arm paresthesias (4/30/03).  [3] SOB/DOE noted 3/12/03 during conversation with colleague, attributed to being out-of-shape, not reported. In retrospect SOB/DOE recalled for 5-7 days prior to 3/12/03, not recalled after that date.  Dermatologic:  [1] Non-healing chronic ulcer at vaccination site covered with thick black eschar. Determination made 4/19/03 by Certified Wound Care Nurse after telephone consultation regarding persistent "scab" and reviewing photos of vaccine wound site progression. Advised to undertake enzymatic debridement. Treatment started 4/26/03, eschar separated 4/27/03 (Day 61 post-vaccination). [2] Tape irritation while wound covered 2/25/03-4/27/03. Superficial lichenification developed, currently peeling.