Initial case was retrieved from the scientific literature on 31 May 2010. A 75-year-old male patient, with a medical history of a recent hospital admission 6 weeks prior for lassitude, pallor, peripheral edema, anemia (hemoglobin 6.6 g/dL), low serum iron, folate, and B12, diagnosed as pernicious anemia, mild hepatosplenomegaly and slightly elevated bilirubin of 1.4 mg/dL, received an injection (route and site not provided) on 29 November 1973 of Yellow Fever Vaccine (lot number and manufacturer unknown). "Six days later he developed flu-like symptoms, with fever, chills, myalgia, nausea, vomiting, mild sore throat, and abdominal pain. He was seen by a physician who noted a temperature of 100 degrees Fahrenheit and prescribed penicillin and an analgesic. The next day, the patient became confused and did not take food or fluids. He was admitted the following day (8 days after vaccination) to the hospital. On the day of the current admission, the patient was found to be moderately obese, lethargic, acutely ill, and complaining of abdominal pain. The temperature was 98.6 degrees Fahrenheit, pulse 120 and blood pressure 84/48. The face appeared swollen, mucus membranes were dry, the abdomen protuberant and generally tender, with liver and spleen palpable on deep inspiration. Serum urea nitrogen (BUN) was 140 mg/dL, glucose 116 mg/dL, total bilirubin 4.4 mg/dL, albumin 2.6 g/dL; alkaline phosphatase, calcium, and phosphorus normal. On the day after admission, he was admitted to the intensive care unit because of hypotension and deteriorating mental status. The blood pressure was 60/40, temperature 102 degrees Fahrenheit, urine output minimal, and sensorium obtunded. The BUN was 190 mg/dL, creatinine 7.8 mg/dL, bilirubin 5.5mg/dL (4.2 direct), SGPT 102 U/L, alkaline phosphatase 93 U/L, hematocrit 46.7%, platelets 46,000, white blood cell (WBC) count 13,800/mm3 with 66% polymorphonuclear cells, 3 % bands, 31%lymphocytes. Urinalysis showed 12-15 WBC, 50-60 red blood cells, 3-4 renal epithelial cells, 2+ albumin. The patient was thought to be in acute renal failure, dehydrated, and to have significant hepatic dysfunction. His condition deteriorated, with progression from delirium to coma. His temperature, BUN, creatinine, and WBC remained elevated. Bilirubin increased to 11.2 mg/dL (9.4 direct). He developed a consumption coagulopathy with thrombocytopenia (40,000/mm3), prolonged prothrombin time (15.4 seconds, 11.4 seconds control) and partial thromboplastin (66.0 seconds, 31.9 control), and positive fibrin split products, but did not develop overt bleeding. He was treated with corticosteroids, mannitol, heparin, furosemide, and vasopressors. The electrocardiogram (EKG) showed low voltage and peaked T waves in V1-V6. Chest x-ray showed fluid in the right pleural space and congestion. The patient died 3 days after admission (11 days after vaccination). On autopsy, gross anatomical findings included diffuse, focal necrosis of the liver, atrophic gastritis of the stomach, lipid depletion of the adrenal glands, and congestion of both lower lobes of the lung. A number of experts evaluated the liver histopathology. The findings included focal single cell necrosis, scattered acidophilic degeneration, marked areas of hepatocellular unrest, marked Kupffer cell hypertrophy, cholestasis, and fatty degeneration. The distribution of lesions was not mid-zonal, and for that reason the changes were not considered caused by yellow fever. A fluorescent stain of the frozen liver was negative for yellow fever antigen and fixed liver tissue was examined by electron microscopy and found negative. Documents held by sender: None.