Report #2897918

Overview

Sex

Female

Age

0.3 yrs

State

ID

Recovered

Recovered

Vaccinated

May 21, 2026

Onset

May 21, 2026

Days to onset

0

Hospital days

—

Symptoms (2)

Symptom narrative

Mother called regarding her infant daughter's reaction following a vaccine administered earlier in the day to the left leg (injection given by nurse after an X-ray visit). Mother reported the patient had been screaming inconsolably for hours after returning home, would not latch to breastfeed during multiple attempts, and was extremely irritable with any movement or repositioning. She would not move her left leg on her own and screamed loudly with diaper changes, with associated shivering-type episodes. Mother had administered Tylenol (total 3 mL, initial dose at approximately 3:40 PM) and applied a cold rice bag to the knee. At the time of the call, the patient was resting but still occasionally crying out in her sleep. Respirations had slowed significantly from a previously counted rate of ~88/min. No fevers noted, though she had been sweating earlier (now resolved). She felt warm on the head but not febrile. No facial swelling, tongue swelling, wheezing, retractions, or respiratory distress. Foot appeared normal with good perfusion. Exam findings per mother: Left leg with taut swelling and warmth. Faint red outline approximately 3 inches long by 1.5 inches wide, located about an inch away from the injection site, extending to the side of and over the knee - not directly at the injection site. Redness had improved slightly with the cold compress. Area remained tender; patient would not move the leg. Discussion and Counseling: Dr. discussed that this presentation is relatively uncommon following vaccination. Reassured mother that there are no signs of anaphylaxis (no facial/tongue swelling, no wheezing, no respiratory distress, no retractions). Explained that the vaccine given was an intramuscular combination (non-live) vaccine, and that the most likely explanation is local inflammation from the vaccine fluid possibly tracking along a muscle or fascial layer, causing localized inflammatory reaction and secondary muscle pain - rather than true joint involvement or infection. Noted that the knee joint capsule is well-separated from surrounding muscle, making joint infection unlikely. Acknowledged a small theoretical risk of skin bacteria introduction with any injection, but overall low. Plan Discussed: -Continue Tylenol 3 mL every 4 hours as needed for pain; reassured mother that Tylenol is safe and appropriate in this situation. May give another dose at the 4-hour mark and continue through the night, including waking for doses if needed to keep her comfortable and help her sleep. -Continue cold compress to the area. -Encourage feeding; if she will not latch, may syringe-feed breast milk or Pedialyte. -Recommended marking the borders of the redness with a pen to monitor for changes in size. -Watch closely over the next 3-9 hours for signs of worsening: increasing redness, streaking down the leg, worsening swelling, fevers, fast heart rate, persistent inconsolability despite Tylenol, continued refusal to feed, persistent refusal to move the leg, lethargy, or toxic appearance. -If any worsening signs develop or if mother is uncomfortable with the patient's appearance, take patient to the ER for evaluation, which may include bedside ultrasound of the area and screening labs (CBC, CMP) Pt was seen in clinic 5/22 developed erythema, swelling, and refusal to move the leg, along with irritability and fussiness. Mom reports that the erythema noted yesterday has since improved. screening labs (CBC, CRP, sed rate, CMP) and an X-ray of the thigh and knee were obtained. The X-ray returned reassuringly normal, with the femur, knee, joints, and soft tissues all looking fine. Labs returned with an elevated white blood cell count at 19,000 with neutrophil predominance at 62 percent, elevated platelets consistent with acute inflammation, normal sed rate, and an elevated CRP at 73.8. Hemoglobin 11.5 and hematocrit 33.8, within normal range for age. CMP showed a low bicarb at 16 suggesting mild/very early dehydration, with normal kidney and liver function. Given the mixed picture, there is a possibility of a bacterial infection, although a large local vaccine reaction remains likely given the timing and known adverse event profile. Reassuringly, Violet's extremity is well perfused without signs of cellulitis, the joint appears intact on exam, and the X-ray is negative. She also remains consolable and non-toxic. Options were further discussed and the following plan arranged: pediatric blood culture (pediatric bottle) to be drawn (mom prefers MC). -Give ceftriaxone 50 mg/kg intramuscular injection at Medical Center after the blood culture is drawn to cover for the next 24 hours while following the blood culture. -Repeat CBC, CRP, and sed rate tomorrow in Gooding; results to be faxed to clinic. -Pending order for a second dose of ceftriaxone tomorrow with verbal approval based on clinical response, blood culture, and repeat labs. -Continue acetaminophen 80 mg suppository every 4 hours as needed for pain/fever. -Encourage good feeding and fluid intake to address mild early dehydration. 5/23 Provider called parent: I called and spoke w/ mom this am. Pt is having improving sx. No fevers. Resolving fussiness. Moving leg. No repeat redness/swelling. No new/worsening signs/sx. Discussed proceeding w/ repeat lab draw and touching base later. In the early evening, labs returned improved, but still not perfect. Nurse from MC called with them. I advised to go ahead and give 2nd dose of CTX and we will continue to follow pt's bld cx through the 48 hr mark and call to check on pt tomorrow. Nurse relayed message to mom who agrees w/ plan.rovider called to check on symptoms:

Current illness

nasal congestion, rhinorrhea, and mild eye swelling

Medical history

Reflux

Other medications

Vitamin D

Allergies

None

Lab data

Xray, labs as described below