The healthcare branch supports quality immunization healthcare for all vaccination programs through a focus on vaccine safety and adverse event surveillance. Healthcare branch was contacted by patient requesting a case review for adverse event following immunizations (AEFI). In 1991, the patient reports experiencing abscesses at vaccination sites, as well as the onset of chronic fatigue, which patient feels is the residual effect of vaccine receipt. The following history is based on telephone interviews and email correspondence with patient, as well as a comprehensive review of available medical and immunization records provided by patient. Patient is currently a 49-year-old male. Immunization records available from between Sep and Dec 1990, but no associated medical records are available. Vaccine History, Sep 1990 - Adenovirus, Meningococcal, Influenza vaccines. Vaccine History 7 Sep 1990, Rubella, Oral Polio, Td and Smallpox Vaccines (SPV, Wyeth, #4898201), TB skin test (Monovax). Vaccine History: 4 Jan 1991, Typhoid, Plague (1.0 ml), and Td vaccines, TB skin test. On 4 Jan 1991, patient received Plague, Tetanus-diphtheria (Td) and typhoid vaccinations, as well as placement of a TB skin test. After training, patient attended school, and then assigned for 3 weeks. With each transfer, his immunization records were lost. Patient believes he received additional vaccinations not reflected in the Vaccine History. Vaccine History: 14 Mar 1991, YF-VAX, TB skin test. On 14 Mar 1991, immunization records reflect receipt of yellow fever vaccine (YF-VAX) and placement of TB skin test. Vaccine History: 18 Mar 1991, Plague vaccine, YF-VAX, TB tine. On 18 Mar 1991, immunization records reflect receipt of YF-VAX and Plague vaccine and placement of TB tine. On 25 Mar 1991, medical records note Chief Complaint: "fever and left arm pain x 1 week". Temperature 100, Pulse 90, BP 140/60, Respirations 20, Medications: Erythromycin. Subjective comments: fever and tiredness; receipt of shots in left arm (possibly typhoid vaccine) during previous week; taking Erythromycin. Objective comments: left arm swollen secondary to shot on Thursday, 14 Mar 1991. Tonsils quite swollen. CBC and Monospot ordered. [Results not visible.] Assessment: "reaction to inoculation" and "sore throat". Plan: Stay on Erythromycin. Quarters x 24 hours. Return to work in 48 hours. Medical Record entries from 16-19 Apr 1991, General Surgery Clinic, are related to dressing changes following incision and drainage (I&D) of mass on left deltoid. Vaccine History: 2 Jun 1991, Plague II vaccine. Vaccine History: 4 Jun 1991, Typhoid vaccine. Vaccine History: 2 Jul 1991, YF-VAX, Typhoid, Td, and Plague II (0.2 ml) vaccines. On 2 Jul 1991, immunization records document receipt of YF-VAX, Typhoid, Td, and Plague II (0.2 ml) vaccines. On 8 Jul 1991, medical records include an acute medical care entry for "hot spot" tender to palpation x 6 days. Temperature 98.7, Pulse 60, BP 107/63, Respirations 14, Medications: None. Subjective comments: 23 year-old male complains of spot on left shoulder. Reaction to vaccine given x 5 days ago, which may have been typhoid or plague vaccine. Objective: 4x5 cm cystic lesion on left lateral deltoid. Small amount of brownish purulent material aspirated. Assessment: Rule out abscess. Plan: Surgery Clinic Consult today. On 8 Jul 1991, medical records include Consult to Surgery Clinic to "rule out abscess". Reason for Request: 23 year-old male complains of hot, tender, cystic lesion to left shoulder x 6 days after plague and typhoid shots. Physical Exam: 4x5 cm, hot, tender cystic lesion with small amount of pus aspirated. Surgery Consultant notes: Patient received vaccinations on Tuesday, 2 July, with onset of pain/erythema and fever to 105 on day of and after vaccination. Seen at Medical Clinic the next day and started Erythromycin and BENADRYL. Afebrile since 48 hours after starting (antibiotics), with erythema decreased, but with persistent pain and fluctuance...had similar episode with prior vaccinations 2 months ago. Physical Exam: 3x3 cm tender/warm/fluctuant area with minimal erythema. Aspirated 3-4 cc pus. Assessment: Left deltoid abscess. I&D and packed with IODOFORM gauze. Culture and sensitivity sent. [Results not visible]. Plan: Return to clinic on 10 July for re-check and packing change. On 10 Jul 1991, General Surgery Clinic notes post-I&D and IODOFORM dressing change following reaction to immunization in left deltoid. On 13 Aug 1991, medical records include Consult to Allergy Clinic to "rule out allergy to Plague/Typhoid". Reason for Request: 23 year-old male complains of adverse reaction to Plague and Typhoid shots x 2. [Consult ordered on 8 Jul 1991.] Pulse 58, BP 110/70, Respirations 12. Allergy Consultant notes: Two episodes of adverse reactions to immunizations in the past 6 months. Reactions consisted of fever/chills approximately 1 day after shots. No rashes. Developed abscesses at site of injection on both occasions. Second episode associated with Plague/Typhoid vaccines. Patient had immunizations earlier without problems. Objective exam: "well developed male in no acute distress. Two well-healed surgical scars over left deltoid region." Impression: Serum Sickness reaction - most likely to typhoid vaccine. Boosters are every 3 years. Plague (vaccine) can be associated with sterile abscesses. Recommendations: No more plaque vaccine. Maintain accurate immunization records. Can get typhoid booster in 3 years. Patient has photo noting "Allergic to  Typhoid/Plague" (vaccines)]. Vaccine History: 1 Oct 1991: Plague III (0.2 ml), Td, and Flu vaccines. On 1 Oct 1991, patient received Plague (0.2 ml), Td, and influenza vaccines. On 5 Oct 1991, Emergency Care Treatment record notes Chief Complaint: "reaction to plague shot". Temperature 97.2, Pulse 73, BP 130/54, Respirations 20. Description: Last Tuesday site swollen. History of adverse reaction to immunization in the past with plague and typhoid (vaccines). Possible sterile abscess formation and increased swelling. No rash. Patient has been followed at Allergy Clinic and needs to return for follow up. Please see within 72 hours. On 17 Oct 1991, medical records include acute medical care entry for "allergic reaction to plague shot x 2 weeks". Temperature 96, Pulse 61, BP 124/68, Respirations 15, Medications: Erythromycin, MOTRIN. Description: 23 year-old male complains of allergic reaction to shots. History of 2 previous abscesses with Plague vaccine. Was evaluated by doctor in August and told no more Plague (vaccine), the patient received Plague booster 2 weeks ago. Exam: Right deltoid with approximately 1 cm mobile mass. No surrounding erythema or exudate. Assessment: Serum reaction to plague (vaccine). Plan: VIBRAMYCIN 100 mg BID. Return to work with follow up in one week. On 23 Oct 1991, medical records include an acute medical care entry for "reaction to plague shot x 1 month". Entry notes this was not patient's first visit for this complaint and that he was being treated with doxycycline and MOTRIN. Temperature 96.4, Pulse 76, BP 120/68, Respirations 17. S: 23 year-old male is returning to clinic following a reaction to a plague shot. Patient has a history of reaction to shots. Seen 5 days ago. Objective comments: Right deltoid without erythema. Slight fluctuance, but appears decreased from last visit. No right axillary adenopathy. Final Disposition: Serum Reaction. Vaccine History: 6 Jan 1992, Hepatitis B (1) vaccine; 22 Feb 1992, Hepatitis B (2) vaccine; 12 June 1992, Hepatitis B (3) vaccine, TB skin test; 08 Oct 1992, Flu vaccine. On 19 Jan 1993, on form, under items checked "yes" with explanation, patient marked "yes" to "Have you ever been a patient in any type of hospitals?" with the following explanations: Swollen, painful joints - especially in the knees and in the back of both hands, less severe in finger joints. Ear/nose/throat trouble - Hearing loss, especially left ear. "Ringing" in both ears. Cramps in legs - occasional sharp pain in thigh area or hip. Adverse Reaction - documented Allergies to typhoid and Plague vaccines. Tumor/growth - 2 times, left shoulder documented. 8 Jul 1991, hospital for minor surgery - Removal of abscess, left arm. Form with no date, but noting "ETS" includes statement - "There has been no significant change in my health since my last physical examination except: loss of hearing, allergy to typhoid and plague vaccine". In addition to above notations from available medical documentation, patient recalls his initial reaction following vaccinations was in March 1991, because that was shortly after he had been promoted. With that reaction, in addition to abscess formation, which occurred within about 1 week of vaccine receipt, he recalls being so sick and falling out the day following receipt of vaccinations. Patient also recalls with his next vaccine reaction, in July 1991, he experienced delirium, with garbled speech and disorientation, associated with a fever of 107. He was treated with IV saline and ice baths, which is not visible in available documentation. Patient recalls immunization records being lost on more than one occasion. He has attempted to obtain copies of all his medical records; from the medical records he has received, he knows there is documentation missing. Patient denies reactions following vaccinations recorded in 1992. During the past 20 years, patient believes the only vaccine he has received was Td-containing vaccination; he denies any subsequent adverse reactions in temporal association to receipt of Td-containing vaccinations. Chronic Fatigue: Patient reports onset of fatigue, around the time he was treated for abscesses at vaccination sites in 1991. At the time, he was able to "push through his fatigue". He also increased his caffeine intake and tried to adjust his activities and lifestyle to help compensate for his decreased energy. The patient worked in jobs involving strenuous manual labor and although he noted he did not have the stamina he used to, and often felt tired during the day, he attributed his fatigue to increased labor and energy expenditure. Patient did not seek evaluation of his ongoing fatigue until 2002, when he was 34-years-old. At that time, he was going to bed around 1830 and sleeping through until after 0600 the following morning. After seeking evaluation, he was diagnosed with hypothyroidism and started thyroid replacement therapy. He noted an increase in his energy and stamina levels; instead of going to bed around 1830, he was able to stay up until 2100 or 2200. This increase in energy level "plateaued". He has had periodic checks of his thyroid-related blood levels since 2002, and reports he has been on the same dose of thyroid replacement medication for more than 15 years. Medical records between 2012 and March 2017, from outpatient visits with patient's healthcare provider, were reviewed and support patient's complaint of chronic fatigue. Consistent reports of fatigue are noted dating back to May 2009. His records note - "fatigue..just wiped out...feels tired all the time". In Jan 2017, patients Primary Care Provider wrote the following - "It is my opinion his current condition of chronic fatigue is at least likely as not to be because of the result of reaction to typhoid immunization and plague. The rationale behind this is that is when his symptoms started in a temporal relationship to this." Currently, patient notes he has difficulty getting up in the morning because he is still tired when the alarm goes off. If he did not force himself to get up, he could sleep for several more hours. Once he is out of bed, his energy is good, compared to how he feels by 1900 - "wiped out". He holds the banister to go up the stairs because he feels so tired and weak. He has difficulty staying awake after 1900, but forces himself to stay up until 2100 or 2200 and to get up by 0700. On the week-ends, he does not allow himself to sleep more than 12 hours and tried not to take prolonged naps (greater than 1 hour) during the day. Patient quit smoking 5 years ago with the hopes he would have more energy, but did not note any significant change in his energy level. Patient's current job involves some lifting, but not extensive manual labor. At home, he engages in physical chores. He does not have a regular exercise regimen. He describes exercise as "sporadic at best". He denies post-exertional malaise; he does not feel his energy levels are significantly less on days following increased physical exertion. He denies symptoms of ongoing or recurrent fevers, recurrent sore throats and swollen glands, multi-joint or muscle pain, chronic headaches, and changes in his memory or concentration. He denies snoring or pauses in breathing followed by gasping or choking. He has not had a sleep study. ROS: Review completed. All negative except as reported in HPI, PMH, and as follows: HEENT - decreased hearing acuity in left ear and tinnitus. History of perforated ear drug and multiple earaches during early childhood. Reports ruptured tympanic membrane in his 30s. History of "shavings" in his eyes requiring extensive rinsing, but no residual problems with vision. Musculoskeletal - chronic knee pain diagnosed as arthritis. Endocrine - As an adult, reports decreased tolerance to heat - "feels hot"; no changes noted with regulation of thyroid medication.