Information has been received from a RN concerning a 42 year old female with pulmonary disease, asthma, arthralgia, hypertension, and sulfa allergy and a history of pneumonia, obesity and benign left breast disease who on 10/29/01 was vaccinated.  The RN stated that within 24 hours of receiving the vaccine the pt experienced a temperature of 101 to 102.6 F, along with localized injection site reaction of the left deltoid.  On 10/31/01 the pt presented to the Dr's office with worsening arthralgia, an elevated WBC of 20,000, vomiting, diarrhea, headache, parathesia and a rash on the left arm and face. A chest x-ray was negative. Subsequently, on 10/31/01, the pt was hospitalized. This is in follow-up to report(s) previously submitted on 11/9/01. Information has been received from a registered nurse concenring a 42 year old obese (231 lbs.) white female with asthma, hypertension, sulfa allergy, hiatal hernia, gastroesophageal reflux disease, hypothyroidism, rhinitis, arthralgia, breast disorder (left breast disease benigh) and lab test abnormality (abnormal mamogram) and a history of pneumonia, total abdominal hysterectomy and bilateral salpingo-cophorectomy for endometriosis, tonsillectomy, partial colectomy, abdominal abscess drainage, joint stiffness, hemoptysis, hypercholesterolemia and intestinal diverticulitis who on 10/29/01 was vaccinated in the left deltoid with pneumococcal vaccine 23 polyvalent (lot 636849/0944K). Concomitant therapy included montelukast sodium, rofecoxib, Claritin, Synthroid, Micardis, Prevacid, estrogene, Premarin, Advair, Ortho-cyclen and Flonase. On 10/30/01, the pt's arm started to hurt, swell and get red. By 4-4:30pm the pt developed a fever. She became nauseated by 8pm, vomited and had diarrhea at approximately 2am. All night she had a fever of 101 to 102.6 F. She had no chest pain, cough or increased shortness of breath. On 10/31/01, the pt presented to the physician's office with worsening of arthralgia, an elevated white blood cell count, vomiting, diarrhea, headache, paresthesia and a rash on the left arm and face. On physical exam her temperature was 102 F. Her left arm was swollen and tender. There was a patch of erythema laterally in the upper arm. The pt complained of worsening arthralgia and joint stiffness since the left arm swelling began, but here was no obvious joint swelling. Her white blood cell count was 20,600 with 87 segs. A chest x-ray showed no acute infiltrate. Subsequently, on 10/31/01, the pt was admitted to the hospital and started on IV fluide, IV Unasyn and placed on clear liquid diet. Her physical exam upon hospitalization revealed a temperature of 101, pulse of 92 and respirations of 12. Chest was clear to auscultation. Cardiovascular revealed a regular rate of rhythm, no S3 gallop, murmur or rub, a positive S4 was heard. Abdomen was soft, non-tender and non-distended. Pelvis was stable. Spine showed no areas of tenderness. Lower extremities showed no deformatities and were moving well. Examination of the left arm showed an area of approximately 6cm in diameter in the upper third of the upper arm, located primarily posteriorly of erythema and slight induration with tenderness to palpation. There was a little bit of tenderness proximal to that area in the region of the shoulder and for approximately 2cm dista. The area around the elbow, forearm, wrist and hand were non-tender. The pt was able to move her fingers well and light touch sensation was intact in the median, ulnar and radial nerve distribution. She had 2+ radial pulse. There was no tenderness on the anterior aspect of the arm. Compartments appeared to be soft and there was no crepitation noted. There was no necrotic skin noted. Shoulder range of motion caused discomfort in the area of the redness and was somewhat limited secondary to the pain although on passive range of motion with the arm at her sides, no significant discomfort. There was no gross fluctuance present. There was no adenopathy in the fractures