Age: 61.0
Sex: M
Vaccine: HEPA, TD, YF, HEPA, TD, YF, DPP, HEPA, YF
Symptoms: Demyelination, Encephalitis, Hemiparesis, Skin ulcer
Clinical narrative: Information has been received from a health professional via an agency concerning a 60 year old male patient who had been previously healthy and who on 4/4/02 was vaccinated with a dose of hepatitis A virus vaccine inactivated (lot # not reported). Additional suspect therapies included vaccination on 4/4/02 with a dose of yellow fever vaccine (lot number not reported) and diphtheria and tetanus toxoids vaccine (lot # not reported). It was unknown if the event occurred in the USA. Approximately six days after vaccination the patient developed left leg weakness. His left-sided weakness subsequently progressed, and by early May he was paretic on the left side. Subsequent work up indicated a demyelinating syndrome, and he was treated with high dose steroids. The patient had subsequently improved to the point that he was ambulating independently without the use of a brace or a cane. Rehabilitation has been remarkably successful. According to the report, the major diagnostic issue at hand was whether the patient's demyelination condition was more consistent with acute disseminated encephalitis (ADEM), a monophasic demyelinating condition sometimes seen in the setting of vaccination or viral infection; or if in fact his condition represented a forme fruste of multiple sclerosis. The patient indicated that he had been previously healthy prior to the onset of his neurological illness in April 2002. He had never experienced any transient neurologic events such as weakness numbness, paresthesias, Lhermitte's phenomenon, transient blindness, or other symptomatolgy. He had no family history of unusual neurologic events. No one in his immediate family had received a diagnosis of multiple sclerosis. The approximately interval from his vaccination to onset of symptoms was around seven days. His illness progressed rather slowly, progressing to point of maximal weakness over the period of about 30 days. He had slowly continued to improve, and he had experienced no subsequent relapses or periods of worsening. He has had no further neuroimaging studies or CSF analyses performed since October 2002, at which time his MRI displayed some amount of resolution of the larger areas of demyelination, as well as several small static white matter lesions. It was reported that data on CSF, which was apparently collected at least twice, has been unavailable for review, but it was noted they were in the process of being obtained. It was noted that for the most part, however, CSF indices were poor differentiators between ADEM and MS. According to the report, given the nature of the patient's illness, the lack of relapse or progression, and the temporal relationship to several vaccinations, the presumptive diagnosis of ADEM was quite likely. Such a slow progression, over a period of 30 days, was a bit long for this clinical entity, but was certainly not exclusionary. A diagnosis of ADEM did not allow for determination of which vaccination might have instigated the demyelination (or, for that matter, whether one of the vaccinations was indeed the instigating event) However, association with vaccination was based on temporal relationship, and the 7-8 day interval between vaccinations and onset of symptoms would be consistent. It was noted that this would appear to be a case of ADEM most likely related to receipt of one three vaccinations. Acute disseminated encephalomyelitis was determined to be an other important medical event (OMIC). Additional information is not expected.