Severe headache, fever, and arm rash after vaccination EUGENE WONG, MD, JONATHAN RIEBER, MD, AND GABRIELLE FLAMM
Given the patient’s symptoms, lumbar puncture was required to rule out a diagnosis of meningitis.
were visible on Gram stain. A stress echocardiogram revealed no clinical, electrocardiographic, or echocardiographic evidence of ischemia. On his third day at the hospital, the patient had no fever, but a 20 ⳯ 10 cm area of erythema was seen on the left arm at the site of the vaccination. No antibiotics were given, as the patient was improving with regard to temperature, and the reaction was likely an immune response to pneumococcal vaccine and not bacterial in origin. Mr. B’s severe headache in the occipital area was worse when standing or sitting and improved when lying down. No photophobia, chills, neck pain, confusion, or visual changes were noted. The headache did not resolve with IV hydration, bed rest, liberal fluid intake, oral analgesics, and IV caffeine. An epidural blood patch placed on the fourth day of Mr. B’s hospital stay completely resolved his headache. The patient remained afebrile, with roughly 90% of the erythema resolved, and he was discharged home the next day. A report was fi led online through the U. S. Department of Health and Human Services’ Vaccine Adverse Event Reporting System (vaers.hhs.gov/index).
1. DISCUSSION
FIGURE 1. Localized redness was noted at the site of the patient’s pneumococcal vaccination.
Mr. B, aged 46 years, had a medical history significant for hypertension. He presented to the hospital with a three-day history of intermittent left-sided chest pain following cocaine use. Vitals on presentation showed temperature 98.4˚F, BP 146/78 mm Hg, heart rate 106 beats per minute, and respiratory rate 12 breaths per minute. Physical examination was unremarkable. As part of an admission order protocol, Mr. B received an influenza vaccine in the right deltoid and a pneumococcal vaccine (Pneumovax) in the left deltoid. On his second day in the hospital, Mr. B had a temperature of 104˚F with sinus tachycardia to 140 beats per minute and was treated with acetaminophen (Tylenol). Localized redness was noted on the left upper arm at the site of injection (Figure 1). The patient also complained of a headache located in the frontal region. Cerebrospinal fluid (CSF) analysis following lumbar puncture showed WBC 9/µL with 92% lymphocytes. No organisms or polymorphonuclear WBCs
CASE #2
Approximately 1.2 million cases of bacterial meningitis occur annually worldwide, resulting in 135,000 deaths. Bacterial meningitis can be difficult to diagnose. Patients may present with the classic triad of fever, nuchal rigidity, and a change in mental status, but in a study of 696 cases of community-acquired bacterial meningitis, only 44% exhibited all three findings.1 The clinical history is generally not useful in diagnosing meningitis. The onset is often subacute with a preceding upper-respiratory-tract infection. Clinical history lacks specificity for diagnosing meningitis, with one prospective trial showing specificity of 15% for a nonpulsatile headache, 50% for a generalized headache, and 60% for nausea and vomiting.2 The definitive diagnosis depends on the results of examination of the CSF. Gram stain of the CSF reveals the causative agent in 70% to 80% of cases and is positive in 80% to 90% of patients with bacterial meningitis.3 The physical exam can provide clues to the diagnosis, including nuchal rigidity, change in mental status, Kernig’s sign, and Brudzinski’s sign. Nuchal rigidity refers to flexion of the neck (either active or passive) with inability to touch the chin to the chest. If full range of motion is present, nuchal rigidity is absent. Continues on page 120
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