22 y/o female, developed unexplained bruising over medial right forearm & right lateral elbow, paresthesia from right elbow to fingertips right hand, muscle, joints & bone pain right arm following receipt of AVA#1, TYPHIM VI & ADACEL vaccines given 7/20/2009. Pt reported receiving AVA and another vaccine in her right upper arm, and one vaccine in her left upper arm. Per electronic immunization record: AVA and TYPHIM VI given in left arm, ADACEL in right arm. Vaccinations were given at 0900. Pt. did not recall any immediate reaction. About 10 minutes later she had a venipuncture in right AC space for routine lab test (one stick/one tube, using vacutainer device) and shortly thereafter felt soreness in right forearm but nothing else at that time. By that evening, she had mild injection site tenderness right deltoid area, without swelling, itching, redness; there was increased tenderness in right forearm. On following day (7/21) she noticed a 1.2 -2 inch bruise located along volar aspect of right forearm, 3-4 inches distal and medial to venipuncture site, no swelling or tenderness directly over bruise, but rest of forearm remained tender. She denied blunt or pressure trauma to this area. over next day bruise increased to maximal 6 inches, progressed distally, without pain or swelling. There was never any discoloration or pain directly over right AC venipuncture site. Other than mild fatigue, there were no other systemic symptoms. On 7/22 pt saw both PCM and Immunization Clinic staff due to her concern about bruise and possible causal connection with AVA - she was advised most likely related to venipuncture; instructed by PCM to use NSAID and heat. Pt tried moist heat that evening (no NSAID) w/o improvement but noticed insensitivity to heat directly over bruise and tingling sensation in forearm. By 7/23, bruise started turning yellow along border and spread around to lateral forearm. By 7/24 she had increased tingling from medial elbow to fingertips of right hand and developed muscle pain/cramps and joint and bone pain throughout right arm from shoulder to wrist; a new unexplained bruise appeared over lateral right elbow (dime size). Pt explored internet and contacted CDC due to her symptoms and growing concern - told to seek care. Pt went to clinic on 7/25 and 7/27 with concern about unexplained bruises and forearm pain; CBCx2, INR, PT, PTT were normal; pt advised to use ice and MOTRIN. Pt denied gum bleeding, blood in urine or stool, GI symptoms. Currently bruises resolving, no new bruises since 7/24. She has been able to function at work and home but has persistent right arm pain from shoulder to wrist, as well as intermittent tingling from right elbow to fingertips and tip of thumb; she has full joint ROM without swelling or redness; no limb weakness. She reported feeling well day of vaccination a and within 30 days prior; no recent neck, shoulder, arm injury/surgery; no regular medications; no allergies to drugs, foods, latex, insect stings; no prior vaccine reactions; no other vaccine receipt within 30 days prior. previous Td received 2005. She has no personal history drug allergies, but family history penicillin allergy, so has never taken it; parents and siblings healthy. Clinic evaluated pt 7/29/2009 with preliminary clinical diagnosis brachial neuritis post vaccination likely related to ADACEL.