On 10/8/99, the pt experienced pain and notified her physician's office. On 10/10/99, the pt presented to the ER with a fever and flu symptoms. The pt was sent home and not admitted to the hospital. The follow up received on 2/24/00 states pt with NKDA, b/o knee osteoarthritis, gastritis, depression and a history of breast carcinoma in 1994 with a local resection who on 9/30/99 was vaccinated IM in the rigth deltoid with a first dose of hep B vaccine. Concomitant vaccinations included tetanus toxoid in the left arm. Concomitant therapy included Zantac 150mg bid, rofecoxib 12.5mg daily, Synthroid 0.15mg po daily, Premarin 0.3mg daily, Prempro 0.625/2.5 daily . On 10/5/99 the pt experienced low back kpain, fever, chills, malaise, weakness and notified her physician's office. On 10/10/99 the pt presented to the ER with a fever of 103 deg F and flu symptoms. It was ntoed that the pt was also evaluated for orthostasis. The pt iproved markedly after receiving one liter of IV fluid in the ER and was sent home. In the ER her WBC count at that time was12,700 and hemoglobin 11.8 which represented a decrease from 13 on 9/9/00. Labs were otherwise normal. The back pain abated promptly in the ER which IV Toradol and subsequently responded very well to oral rofecoxib 12.5mg taken at home. Generally, the pt felt better after 10/10/99 but the fever never completely resolved and she continued to complain of fatigue and weakness. She was able to take in food and fluids, however. On office follow-up, had decreased to 10.8. Her erythrocyte sed rate was 124 and her chemistry-13 was normal except for a albumin of 3.0. Cultures of blood and urine from 10/10/99 were negative. A review of systems was remarkable for "blurry" vision and a moderate headache off and on with intermittent chest wall pain and chronic cough and dyspnea on exertion. The cough had been non-productive. THere wano orthopnea or aroxysmal nocturnal dyspnea and no amesis or diarrhea, constipation or complain of low back pain radiating to the right hip mostly resolved and left ankle swelling for approximately 48 hrs prior to the admission. Physical examination rrevealed a pale, sallow female in no apparent distress except mild dyspnea when talking. Vital signs were stable with weight 174 pounds. Head and neck: sclerae antiicteric. Nose and throat were clear and ears were normal. Neck had no lymphadenopathy with full range of motion without pain and no jugular vanous distension or bruit. Her chest was clear to percussion and auscultation. Breasts were dense without any palpable masses. Heart rate and rhythm were regular with normal S1 and S2, no gallop or murmur. Abdomen was benign. Stool was hema negative. Her extremities with normal pulses and good range of motion with a scar on the medial right knee with retropatellar crepitus. There was trace ankle edema. Neurologically she was alert and oriented ot person, place and time, cranial nerves II-EII were grossly within normal limits. Motor and sensory examinations were nomal. Deep tendon reflexes were normal and there wasa no cerebellar signs. her skin and tissues were normal except for a nodular density in the left axilla. Lab test on admission revealed: WBC 9,6000, hemoglobin 10.8, hematocrit 32.5 with MCV 93, platelets 302,000. Chemistry-13 was normal except for albumin of 3.0, LDH 623, reticulocyte count 0.5, sed rate 124 and oxygen sat 95% on room air. The pt was placed on bed rest and given IV fluids. A hematology consultation was obtained and a fine needle aspiration of hte left axillary lymph node was attempted. A chest x-ray showed a left pleural effusion and because of the pt's increasing shortness of breath, a pulmonary consultation was obtained. A thoracentesis was performed on 10/24/99. There was evidence of a small left pneumothorax, but this was followed without chest tube placement and with analgesics and repeat chest x0rays. The pleural fluid was transudative and cytology ultimately was negative. Hemoglobin and hematocrit continued to decrease slightly. The serum iron was 8 with total iron binding capacity of 242. Antinuclear antibody was negative, CH-50 3. A CT scan of the chest and abdomen revealed moderate left pleural effision with stelactasia, also left suprraclavicular and left hilar adenopathy with several non-enlarged nodes present in the right hilar region. Hepatosplenomegaly and numerous nodes were present in the retroperitoneum, one of which appeared to be enlarged. Bone marrow aspiration and biopsy were perfomred on 10/27/99. Other lab tests performed during hospitalization are as follows: LDH 449, serum haptoglobin 523, hemoglobin at the time of discharge 12.2 and hematocrit 36.5. Pleural fluid cell count: WBC 3,000, RBC 5,300, 40% lymphocytes, 29% neutrohils. Blood cultures, pleural fluid and cultures were negative. Direct antiglobulin test was negative, antinuclear antibodies were less than 1:40, protein electrophorosis abnormal for albumin 2.8. Cytomegalovirus IgM was negative. Epstein-Barr virus was IgG positive with IgM negative, cold agglutinin was less than 1:40. Parovirus B19 antibodies IgG 1.09. IgM 0.36, vitamin B12 level was 535, folate 10.8. Room arterial blood gas: pH 7.13, pCO2 31, pO2 as with O2 sat 97%. Final report of bone marrow aspiration and biopsy rervelaed peripheral blood showing a normochromic, normocytic anemia with pelgaroid morphology in the granulocytic population. The bone marrow showed a mildly hypocellular marrow with numerous lymphoid aggregates and focal collection of epithelial histiocytes suggestive of eraly granuloma formation. There was adequate erythropolesis, granulopoiesis and  megakaryocytopoiesis. There was no evidence of malignant lymphoma, no evidnece of mycobacterial or fungal organisms. There were adequate iron stores. The pt was discharged on 10/28/99 in fair condition reporting that she still felt weak and had exertional dyspnea but that her symptoms had improved significantly. She was to have close outpatient follow-up dietary or activity restriction. Her daily medications remained the same except for the addition of ferrous sulfate 325mg daily. According to the reporting physician, the pt had recovered. Additionally, the reporting physician indicated that he believes "that she experienced an adverse reaction to hep B vaccine."