Age: 35.0
Sex: M
Vaccine: DTP
Symptoms: Areflexia, Beta-2 glycoprotein antibody negative, CSF protein increased, CSF white blood cell count negative, Decreased vibratory sense
Clinical narrative: This case was reported in a literature article and described the occurrence of distal acquired demyelinating symmetric neuropathy in a 35-year-old male subject who was vaccinated with DTP (manufacturer unspecified). The subject was previously healthy. On an unspecified date the subject received unspecified dose of DTP (unknown route, unknown injection site). Lot number not provided. 2 weeks after vaccination with DTP, the subject experienced progressive distal symmetric numbness and paraesthesias. Paraesthesias initially affected only the distal portions of his hands and feet. Over the following month, sensory loss developed in the same areas. Sensory loss and paraesthesias progressed over the next month to affect the legs below the knees and arms below the elbows. Two months into his disease course, he could walk without assistance but with a slow broad-based gait. Three months into his disease course, he could not ambulate independently. The subject was diagnosed with distal acquired symmetric demyelinating polyneuropathy. This case was assessed as medically serious by GSK. Three months after symptom onset, examination demonstrated severely diminished vibration, distal loss of pin sensation, areflexia, and normal strength. Laboratory studies revealed normal vitamin B12, vitamin B6, HIV, RPR, and serum immunofixation (no monoclonal protein). Antibodies against myelin-associated glycoprotein (MAG), GQ1b, GD1a, GD1b, antinuclear antibody, anti-Ro, anti-La, and anti-Hu were absent. Cerebral spinal fluid (CSF) demonstrated elevated protein (74 mg/dL) without white blood cells. Nerve conduction studies (NCSs) were notable for prolonged distal latencies in median, ulnar, peroneal, and tibial motor nerves (30%-50% above upper limit of normal) and median, ulnar, and sural sensory nerves. Mild conduction velocity slowing was observed in several nerves. The F waves were absent (peroneal) or mildly prolonged. No conduction block or temporal dispersion was present. Limb temperature was more than 32 deg C. The subject was treated with normal immunoglobulin (IVIG). Three months after treatment, initiation examination showed vibration and pin loss only in his feet and fingertips. Reflexes were present but hypoactive. He could ambulate independently but was unsteady and not able to perform tandem gait. Six months after treatment initiation, only a mild degree of vibration loss remained in his toes. Pin testing and reflexes normalized. Gait was stable, and tandem gait was performed without difficulty. Strength remained normal during the disease course. Vaccine-associated distal acquired demyelinating symmetric neuropathy (DADS) may suggest a vaccine- triggered immunologic event directed against myelin associated glycoprotein below detectable concentrations. More likely, we suspect vaccination in this subject triggered an immune response against currently unrecognized antigens and manifested as restricted chronic inflammatory  demyelinating polyradiculoneuropathy (CIDP) in the form of demyelinating symmetric neuropathy. Vaccine-associated CIDP is a rare but poorly characterized event that should not discourage at-risk individuals from being vaccinated. Nonetheless, vaccine safety and public reassurance rely on rapid detection and treatment of adverse outcomes. DADS neuropathy can occur after vaccine. We suggest consideration of this diagnosis for patients with new sensory symptoms after vaccination.