5th Annual Advocacy Project: ImmuneWise

Section on Medical Students, Residents, and Fellowship Trainees

2009-2010

Morning Report

CC: 12 month old male with rash

CC: 12 month old male with rash

You are in the busy emergency department at the community hospital…

What questions do you want to start with?

CC: 12 month old male with rash

• 12 month old awoke with small spots on his face (right side > left) and fainter spots on his stomach and back

• He went to his pediatrician this morning for evaluation

• The rash worsened/spread this afternoon/evening to include genitals, legs, palms of his hands – more confluent and itchy

CC: 12 month old male with rash

ROS:

• Decreased PO intake today (UOP x 3)• Tactile fever• Rhinorrhea this evening• No vomiting or diarrhea• No blisters or vesicles• No ingestions/medications

CC: 12 month old male with rash

• General: Happy infant with diffuse rash• T 36.8 HR 120 RR 30 Pain 0/10• HEENT: NC/AT, EOMI, no conjunctival injection,

no oral lesions or erythema• Neck: Supple, no LAD• Chest: Lungs CTA, HRRR• Abd: Normal bowel sounds, soft, NT, no HSM

CC: 12 month old male with rash

Differential Diagnosis

- Discussion

Management

Erythema Multiforme Minor• Self-limiting

• Acute onset of acral and symmetrical erythematous papules evolving into target lesions

• Relative absence of constitutional symptoms

• Most commonly caused by infections, especially by HSV and Mycoplasma pneumoniae

MMR Vaccine Reactions• Pain, redness, swelling at the site

• Fever in 5-15%, with an onset within the 6-12 days following injection

• Non-specific rash in 5%, particularly within the second week following vaccination (more common with MMRV than MMR)– One case report from Bernardini et al. Erythema multiforme following

live attenuated trivalent measles-mumps-rubella vaccine– Finnish studies show EM minor from MMR to be common

• Thrombocytopenia associated with measles component

• Arthritis/Arthralgias associated with rubella component

Vaccine Adverse Events Reporting System (VAERS)

• Cooperative program of the CDC and FDA started in 1990

• Post-marketing safety surveillance program• Passive reporting system• Collects information about adverse events that

occur after the administration of US licensed vaccines

• Can identify safety signal but cannot determine causation

Vaccine Adverse Events Reporting System (VAERS)

–Who reports?• Health care professionals, manufacturers, parents, state

immunization programs

–What to report?• Any event after a vaccine concerning to the reporter –

fever, rash, seizure, fainting, etc.• A reporter does not have to be certain the vaccine

caused the event

–Why report?• To improve vaccine safety and strengthen public trust in

the FDA and CDC

–How to report?• http://vaers.hhs.gov/• 1-800-822-7967

Reporting Adverse Reactions

Vaccine Adverse Events Reporting System (VAERS)

• National Childhood Vaccine Injury Act requires physicians to report two events to VAERS

1. Any event listed by the manufacturer as a contraindication to subsequent vaccine dosages

2. Any event listed in the Reportable Events Table that occurs within the specified time period after the

vaccination

Exam Questionsabout

Vaccine Reactions

Vaccine ReactionsCME questions from Pediatric Emergency Care

• Which of the following vaccines is most strongly associated with hypotonic-hyporesponsive episodes?

A. MMRB. DTaPC. IPVD. Pneumococcal conjugateE. Hib

Vaccine ReactionsCME questions from Pediatric Emergency Care

• Which of the following vaccines is most strongly associated with hypotonic-hyporesponsive episodes?

A. MMRB. DTaP – episodes occur within the first 48 hours; lasts 1 minute to 48 hoursC. IPVD. Pneumococcal conjugateE. Hib

Vaccine ReactionsCME questions from Pediatric Emergency Care

• Which of the following vaccines has a known association with protracted inconsolable crying?

A. Hep BB. IPVC. MMRD. DTaPE. Pneumococcal conjugate

Vaccine ReactionsCME questions from Pediatric Emergency Care

• Which of the following vaccines has a known association with protracted inconsolable crying?

A. Hep BB. IPVC. MMRD. DTaP – events lasting > 3 hours and occurring within 48 hours of injectionE. Pneumococcal conjugate

Vaccine ReactionsCME questions from Pediatric Emergency Care

• Which of the following vaccines is most likely to be implicated as causing thrombocytopenia?

A. IPVB. MMRC. HibD. Pneumococcal conjugateE. Hep B

Vaccine ReactionsCME questions from Pediatric Emergency Care

• Which of the following vaccines is most likely to be implicated as causing thrombocytopenia?

A. IPVB. MMR – 1 in 30,000 doses (0.003%), usually 2-3 weeks post vaccineC. HibD. Pneumococcal conjugateE. Hep B