Adolescent with osteomyelitis after intramuscular administration of a vaccine: A case report.

OBJECTIVE: To emphasize adverse outcomes associated with applying adult immunization protocols to the pediatric population. CASE SUMMARY: A 15-year-old female with no past medical history developed severe pain in her left arm and decreased range of motion 11 days after receiving an intramuscular injection of the human papillomavirus vaccine. Over the following month, she was treated with a short course of steroids for frozen shoulder and gabapentin for Parsonage-Turner syndrome. During the third visit to a specialist for severe pain and loss of left arm mobility, she was sent to the emergency department for further workup. An x-ray and magnetic resonance imaging of the left arm were suspicious for osteomyelitis. The diagnosis was confirmed by incision and drainage of the abscess and a bone biopsy. A 6-week course of antibiotic therapy was initiated after the biopsy results. The injury was attributed to overpenetration by the needle during the intramuscular injection she had received in the previous month. PRACTICE IMPLICATIONS: As the number of states allowing pharmacists to vaccinate patients of all ages grows, pharmacists must be prepared to safely provide vaccinations to patients of varying sizes. Assessing body habitus while balancing the constant responsibilities of a community pharmacy will be a challenge. Introduction of a guidance document with specific needle lengths based on weight, age, and sex can address potential errors before they occur.