A 42-year-old woman comes to the office in October for a follow-up visit 3 weeks after being hospitalized for abdominal swelling. The patient reports that she has occasional fatigue but is otherwise feeling well. She has been taking lactulose, spironolactone, and furosemide with some improvement in her symptoms. The patient drank 12 beers daily for 15 years but has been sober for the past 3 months. She does not use tobacco or illicit drugs. When asked about her immunization history, the patient recalls receiving all appropriate childhood vaccines and a tetanus-diphtheria toxoids booster following a traumatic injury at age 31; she does not recall receiving any vaccines since then. Physical examination reveals mild jaundice, palmar erythema, a slightly distended abdomen, and spider angiomas. Laboratory results are as follows: Which of the following immunizations are recommended for this patient?
PPSV23 = 23-valent pneumococcal polysaccharide vaccine
Tdap = tetanus-reduced diphtheria-acellular pertussis vaccine

Question

A 42-year-old woman comes to the office in October for a follow-up visit 3 weeks after being hospitalized for abdominal swelling.  The patient reports that she has occasional fatigue but is otherwise feeling well.  She has been taking lactulose, spironolactone, and furosemide with some improvement in her symptoms.  The patient drank 12 beers daily for 15 years but has been sober for the past 3 months.  She does not use tobacco or illicit drugs.  When asked about her immunization history, the patient recalls receiving all appropriate childhood vaccines and a tetanus-diphtheria toxoids booster following a traumatic injury at age 31; she does not recall receiving any vaccines since then.  Physical examination reveals mild jaundice, palmar erythema, a slightly distended abdomen, and spider angiomas.  Laboratory results are as follows:  Which of the following immunizations are recommended for this patient?
PPSV23 = 23-valent pneumococcal polysaccharide vaccine
Tdap = tetanus-reduced diphtheria-acellular pertussis vaccine

Quizplus · Accepted Answer

11ec25c8_d226_395e_bc81_1d9b0542f322_MD0003_00 This patient has clinical features consistent with cirrhosis due to alcohol abuse. Patients with chronic liver disease require the same immunizations as the general population in addition to disease-specific vaccines. The influenza vaccine is recommended annually for all adults (Choice B). The intramuscular inactivated influenza vaccine appears to be more effective than the live attenuated intranasal vaccine and is preferred. All adults should receive a tetanus vaccine every 10 years, either with the tetanus-diphtheria toxoids vaccine (Td) or the tetanus-reduce diphtheria-acellular pertussis vaccine (Tdap). For adults who have not received Tdap, at least one dose of Tdap should be given. Pneumococcal vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPSV23) is recommended for all adults age ≥65 and for those age <65 with certain comorbid conditions that increase risk of pneumococcal disease (eg, chronic liver, lung, heart disease; diabetes mellitus; smoking). Because this patient has cirrhosis (ie, chronic liver disease), she should be vaccinated with PPSV23. Patients with chronic liver disease who contract viral hepatitis are at increased risk for hepatic decompensation. For this reason, they should receive vaccination against hepatitis A and B unless they have documented evidence of immunity. Because this patient's hepatitis serologies do not indicate immunity, both vaccines should be administered (Choice E). (Choices A and C) Given that this patient's last tetanus vaccination was ≥10 years ago, she is due for one now. The pneumococcal vaccine should be added because she has cirrhosis. Educational objective: Patients with chronic liver disease require the same immunizations as the general population and additional disease-specific vaccines, including hepatitis A and B vaccines as well as the 23-valent pneumococcal polysaccharide vaccine. References: Cirrhosis: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/31845776)

A 42-Year-Old Woman Comes to the Office in October for a Follow-Up