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Life Threatening? Yes
Write-up: Immediately following vaccine, patient began to complain of mild symptoms (my shoulder hurts, my wrist hurts, look at these spots on my leg. On the 5th of January, she came home from school with pain in both of her ankles but after resting and and Advil, she felt ok to go school. She came home from school on the 6th screaming in pain. Her ankles were so swollen, we had a lot of trouble getting her boots off. She couldn''t walk and had a rash all over her legs and ankles. We saw a pediatrician who immediately sent us to hospital. She had lots of tests and IV steroids and antibiotics. They later diagnosed her with Lupus. PCP records received as well as note from admission DOS 7/7-12/2009. Pt initially presented Jan 8, 2008 with c/o 5 day hx of bilateral ankle pain and rash of the ankle, calf and thigh. Seen in ER with PE (+) for petechial purpuric rash and low grade fever. Tx with abx and steroids and d/c for outpt f/u. Rheum consult PE (+) for L ankle effusion and decreased ROM. R ankle (+) for synovial thickening. Scant petechial lesions on LEs. ? Gardasil trigger for autoimmune disease with arthritis. F/U 1/15/09 with dx: Lupus. F/U 2/19/09, 4/6/09 with Impression: The presence of anti-histone AB suggests drug-induced Lupus 2'' to Gardasil. F/U 6/22/09 with c/o H/A, joint pain, mouth sores and rash. Assess: Worsening Lupus now with nephritis. Admitted 7/7-12/09 with D/C DX: Lupus cerebritis, lupus glomerulonephritis for c/o difficulty with word finding and increasing clumsiness. Nephrology consult for hematuria and proteinuria. 7/31/09 Hospital discharge summary received DOS 7/7/09 to 7/12/09. Assessment: Lupus cerebritis, lupus glomerulonephritis. Patient presented with 6 days of increasing difficulty finding words and general confusion. Choreiform movements and difficulty with memory. Palmar peeling after Cytoxan treatment. Papules on tongue. Malar rash. ICD-9: Diagnosis 710.0 Systemic lupus erythematosus Other causes of encephalitis and encephalomyelitis: 323.814,
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