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Ask the Expert - Evaluation and Management of Possible Immunization Reaction (December 2010)

Question: 

A 29 month old with a history of mild reactive airway disease presented to me for evaluation of a possible immunization reaction.

At 28 months, the patient received his first Hep A, second Hib-PRP-T, and third DTaP-HepB-IPV.  Unfortunately, the locations of the vaccinations were not documented.  Four hours post vaccination, mild lip angioedema and periorbital edema developed.  At 8 hours post vaccination, a quarter sized local reaction on the right thigh was noted.  On post vaccination day 1 the local reaction was now ~half dollar sized, though the lip angioedema and periorbital edema disappeared.   On post vaccination day 2, the local reaction nearly circled the right leg.  The patient was seen by his PMD who also noted 2 small urticarial lesions on the face.  The patient was reassured by the PMD that it was a reaction to the vaccine and to continue to monitor the lesions.  On post vaccination day 3, the patient developed generalized urticaria ( without respiratory distress), as well as an increased local reaction in the right leg.  The patient was taken to a local ER and treated with Benadryl and Keflex.   Over the next 4-5 days, the urticaria and local reaction resolved.  By the time he presented to my office, which was post vaccination day 14, the patient’s examination was normal.  His history was otherwise unremarkable to the present illness( i.e. no new medications, foods, etc.).
What would you recommend for the work up and future immunizations for this patient?

Answer: 

This is not an uncommon presentation, since infants and toddlers now get several vaccines at once and several of the vaccines are combined.  Firstly, it is important that you obtain an actual copy of the immunization administration sheet from the PCP, listing the manufacturer and the type of vaccine administered, as well as the previous doses given and their dates.  

It seems that this child developed a mixed picture of immediate and delayed generalized reactions as well as a large local reaction to the vaccination.  This child seems to have been delayed in his/her vaccination schedule as well. Therefore a catch-up immunization schedule, rather than the regular immunization schedule, is to be used (per American Academy of Pediatrics Red Book).

A reasonable approach is to examine the immunization record and determine which vaccinations are still needed from the list of the ones that may be associated with the reaction.  For the vaccine series that have been completed, let the family know that they will not need any further doses.  For the ones requiring further doses immediately, one should individually test each vaccine.  If the tests are negative, these are each administered separately, and if possible from a single vaccine preparation.  The child should then be monitored for half an hour after each administration.  If a vaccine tests positive, decide with the family whether to  administer in a graded fashion or to not administer at all, and follow the immunization titer over time.  Testing is typically done with a prick test at 1:10, then full strength, then by an intradermal test with a 1:100 dilution.

Using this case as an illustration: At age 28 months, the patient received his first Hep A, second Hib-PRP-T, and third DTaP-HepB-IPV.

This child will not need: Hep-B vaccine (received 3 doses)
This child will not need another Hib dose since he/she is already 29 months and has received two doses of Hib
This child will need a fourth dose of DTaP in 6 months (and one more dose in another 6 months)
This child will need a fourth dose of IPV in 6 months
This child will need a second dose of Hep A in 6 months.

In this case, bring the child back in 6 months, and in one visit test to the IPV, IPOL (Aventis Pasteur) and give the same vaccine used for testing, if testing is negative.  In another visit (at least a week later) test to the Hep A and give the same vaccine use for testing, if testing is negative.

Then, bring the child back a third time and test with: DTaP Tripedia (Sanofi Pasteur) or Infanrix (GSK), whichever one the child had received, DT (SanofiPasteur) and TT (Sanofi Pasteur).   By a process of deduction, one can figure out to which of the components of the vaccine the child may have reacted. Thus, if testing is positive to DTaP, but neither the DT or the TT, this implies the child may have reacted to the aP part. The child therefore would receive the DT and the pertussis would be omitted.

Not infrequently in such clinical scenarios, testing is negative to all vaccines, and each vaccine is tolerated individually without any side effects!

 
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