It was reported in a published article that a 28 week old previously healthy male patient was vaccinated at approximately 13:20 PM on an unspecified date with a dose of hepatitis B virus vaccine (+) HIB conjugate vaccine. Suspect vaccinations received at the same time included a dose of poliovirus vaccine inactivated, a dose of diphtheria toxoid (+) pertussis acellular vaccine (+) tetanus toxoid, and a dose of pneumococcal 4 6B 9V 14 18C 19F 23F conjugate vaccine. Eight hours later, at approximately 21:30, the patient was difficult to arouse, was limp, had blue extremities that were cool to touch and had a rectal temperature of 104.3 degrees F. The patient arrived at a local emergency department at 22:25. The patient was ill appearing and crying but consolable. The patient was easy to arouse, had appropriate tone and was no longer cyanotic. His temperature was 103.7 F (rectal), pulse was 200, a blood pressure was not recorded and his extremities were mottled and cool. White blood cell count was 7.2x109/L, hemoglobin 12.3 g/dL, hematocrit 35%, and platelets 304x109/L. Serum electrolytes, blood urea nitrogen, creatine and glucose were normal. A roentgenogram of the chest was normal. The patient received 20ml/kg normal saline and 100 mg/kg ceftriaxone IV. The patient's heart rate decreased after the fluid administration, and sinus tachycardia (140-190) was documented on a rhythm strip recorded during transport to the hospital. At the hospital, vital signs were: temperature 100.6 F rectal, pulse 180/min, respiratory rate 30/min, blood pressure 101/57mmHg. Pulse oximetry was 100% on room air. The patient was responsive and had appropriate tone and color. THe patient appeared ill and cried intermittently but did not appear toxic. The patient had a macular, erythematous rash on his cheeks, an erythematous macular rash with satellite lesions in the diaper area and scattered, elevated white plaques on the buccal mucosa and tongue. No local reaction to vaccine administration was noted. The remainder of the examination was normal. The patient had no further hypotonic-hyporesponsive episodes. Tests for respiratory syncytial virus, influenza, parainfluenza and adenovirus were negative. Serum electrolytes were normal. Blood cultures obtained after 1 dose of ceftriaxone were sterile. A second dose of ceftriaxone (50mg/kg) was given 24 hours after admission. The patient defervesced within 40 hours of admission and remained afebrile for the remainder of the hospital course. The patient was treated for thrush and Condida diaper dermatitis and was discharged home with no antibacterial agents prescribed after 62 hours of hospitalization. The patient continued to receive scheduled immunizations except pertussis. The primary care physician caring for the patient elected to withhold future doses of pertussis vaccine. The patient has not had further adverse events associated with vaccine administration. The patient had an HHE that lasted for approximately 50 minutes occurring within 8 hours of receiving antigens from 15 different bacteria and viruses (IV poliovirus) (3), DTaP (3), HIB/HBV (2), and 7-valent pneumococcal conjugate vaccine (7). Statistically HHE's most often follow the administration of pertussis containing vaccine, but there is no way to know which antigen(s), if any, was responsible for this episode. A copy of the published article is attached as further documentation of the patient's experience.