Left deltoid superior aspect with small eschar and no local redness, inferior aspect of deltoid, small eschar with local redness and mild edema, pink/violaceous irregular rash inferior to deltoid but congrunet with inferior injection site. Superficial tactile sensitivy but no significant induration, no soft tissue or bony defect. Distal to mid portion of upper arm is slightly pale lacey purplish/mottled area. Distal forearm and hand normal. Notes: MCV-4 appears to be the presumed trigger for this fixed local reaction. It’s expected to diffuse in the next 3-4 days. May migrate with gravity. May treat locally with ice/heat if needed, may continue experience sensory sensitivity of skin until rash is resolved. Discussed okay to tentatively plan to repeat vaccine when due at 16 years. Fixed local reaction does not appear to be in the spectrum of allergy with risk of systemic allergy or dangerous consequences. Patient is uniquie in circumstances as his liklihood of reaction may be a reflection of the pooled immunoglobulin he gets for his hypogammaglobulinemia. May address with Immunologist if parents wish. VAERS report to be filed.