Age: 1.25
Sex: M
Vaccine: MMR
Symptoms: Autism, Speech disorder
Clinical narrative: Information has been received from a mother concerning her 46 month old son with no prior medical history and no allergies who on 11/29/99 was vaccinated with a dose of MMR (second generation). There was no concomitant medication. On 7/11/02 the patient was diagnosed with autism. Medical attention was sought. No diagnostic labs were performed and no treatment was required. The patient's autism persisted. The reporter felt that autism was disabling because the patient had to have speech therapy. Autism was considered disabling. Additional information has been requested. Follow up on 09/30/2003: "Initial and follow up information has been received from a physician, a nurse, and a mother concerning her 46 month old son with no prior medical history and no allergies who on 11/29/1999 was vaccinated in the right leg with a first dose of MMRII (Lot # 632457/1084J).  There was no concomitant medication and no illness noted that the time of vaccination.  On 07/11/2002 the patient was diagnosed with autism.  Medical attention was sought.  No diagnostic labs were performed and no treatment was required.  The patients autism persisted.  The patient's mother felt that autism was disabling because the patient had to have speech therapy.  The physician noted that the patient's felt the diagnosis of autism was related to the MMRII.  Autism was considered to be disabling.  Additional information is not exptected." A 15-day follow up report received 10/20/2003 adds: The pt was born following an uneventful pregnancy at term via cesarean section due to failure to progress (also noted as elective cesarean section due to a number of procedures for endometriosis). It was noted that at delivery, the pt had the cord around his neck. Apgars of 8 and 9. There was no prenatal infections or complications. the pt did have a conjunctivitis which was negative for Chlamydia on culture. The pt had no known drug allergies. On 09/26/1998, at the age of one month, the pt was seen in the ER for fever, lethargy and diarrhea. There were no hospitalizations, operations, medications, or specifically identified allergies. Immunizations were up-to-date and were well-tolerated. He was negative for convulsions or [[name]] injuries, or loss of consciousness, cardiac conditions, pulmonary problems, maldigestion, or abnormal bowel movements, urinary difficulties, orthopedic problems, or skin conditions. He does bruise easily. There was a family history of autism, apparently severe, in the child of a paternal second cousin. There was also a speech delay in a different paternal second cousin. There were no major concerns during the pt's infancy and he walked at approximately one year of age. However, language did not develop very well and by 18 months his parents were concerned, especially about language delay. At 18 months of age, he seemed to go off on a pathway of his own. His language became jargon, or even a foreign language. On 05/17/2001, at the age of 2.5 years, the pt was seen for a hearing assessment due to concerns with speech and language development. Sound field responses to speech and pure tones were obtained within normal range, using visual reinforcement audiometry. Results of tympanometry showed tympanic compliance and middle ear pressure for each ear. On 05/30/2001, at the age of 2.5 years, the pt was seen for a hearing assessment due to concerns with speech and language development. Sound field reponses to speech and pure tones were obtained within normal range, using visual reinforcement audiometry. Results of tympanometry showed normal tympanic compliance and middle ear pressure for each ear. On 05/30/2001, at the age of 2 years 9 months, the pt was seen for a speech/language pathology evaluation. The Preschool Language Scale-3 was attempted. He was unable to sit and attend to any aspect of the test for more than approx 30 seconds. He was able to complete the test items as he climbed about the room however he became quite upset if physically assisted to sit down. Results of the auditory comprehension portion of the PLS-3 reveal a standard score of 65 and an age equivalent of 1 year 3 months. It was possible for that he would have been able to score higher had he been willing to attend longer, although his lack of attention may be due to the lack of understanding. For the expressive communication portion of the PLS-3, he achieved a standard score of 61 and an age equivalent of 1 year. He was observed to communicate through the use of grunts, whining and grabbing. His vocalizations contained no consonants. Weekly speech and language therapy was strongly recommended. It was to assist the pt with his understanding and use of language, it will improve his attention and behavior as well. In September 2001, at the age of 3 years 8 months, the pt was seen by a developmental pediatrician for evaluation of delayed speech, body tremors, and difficult behaviors. The pt had made some [[name]] progress with early intervention with behaviors and socialization, as well as in his expressive language. The pt hated changes. He got easily frustrated and will throw temper tantrums. He does do some mandatory organizing, that was compulsions. They must follow the same routine or he gets upset. He squints and rubs his eyes a lot. He had an intermittent tremor of the hands, and sometimes of the legs. He runs well, but shortly he gets uncoordinated and stumbles. He was [[name]]strong and stubborn. He was a visual learner. They described that he had always been affectionate and was appropriately protective of his younger brother. He did not like to be touched at the [[name]]. He had great difficulties with water, such as bathing, but this had improved over time. Whenever they drove on curvy or uneven roads, he would get carsick. For example, he had emesis 3 times while on the way for this appointment. He can drink from a cup as well as from a straw, though he demanded to drink from his baby bottle. The parents clarified that they have just not been structured about discontinuing the baby bottle. He was not toilet-trained. He cannot pedal a tricycle, though he can sit at an appropriate position, he was just not coordinated enough for pedaling. He scribbed mainly with his left hand, though he can hold a pen very nicely. He preferred food items that dissolve easily. On physical exam, his weight was 15.2kg (50th percentile), height 99.0cm (50th percentile) and [[name]] circumference 50.5cm (75th percentile). Physical findings were all within normal limits. The physician indicated that the pt had a significant expressive language disorder with difficulty in articulation and intelligibility. He demonstrated poor socialization and mild sensory intolerances. The pt was diagnosed with either dyspraxia or mild autism spectrum disorder or perhaps even a combination of the two. On 07/11/2002, at the age of 3 years 10 months, the pt was seen by a developmental pediatrician for concerns with severe speech delay, occasional tremoring especially of the hands and upper extremities, socialization issues, resistant to change from routines, and fixations on certain activities. He had been weaned from the bottle and will now drink from a cup and eat more solid foods. He would have tremors of his hands and upper extremities when he was trying to do a fine motor activity and at night when he was in bed. He has not had any obvious seizures and no known [[name]] injuries. He had a number of ear infections when he was younger, but these have slacked off and he hears very well. His clumsiness had improved. The pt's hearing was assessed by pediatric audiology, but no results were mentioned. The pt was also seen by a occupational therapist who felt that he demonstrated symptoms that were consistent with a diagnosis of an autism spectrum disorder. He had delayed language skills, intense areas of interest, and delayed social skills and decreased engagement and interaction. He also demonstrated delays in his fine motor skills. It was difficult to get him to do things on direct request. He was also very perseverative in his play. The therapist did not observe many tremors during the examination. The pt was also seen by a speech and language pathologist who administered the Preschool Language Scale, Fourth Edition. On this, his comprehension was 67, expressive score 80 (100 is average). The age equivalent for comprehension was 2 years 3 months, for expressive was 2 years 8 months. The therapist noted that it was difficult to keep him on task. It was noted that based on the parental report, observations, and formal language testing, that the pt's receptive and expressive language were disordered. He also demonstrated an articulation disorder. The diagnoses included: developmental delay, expressive/receptive language disorder, articulation disorder, and autism spectrum disorder. A psychologist also evaluted the pt with the Bayley scale and estimated developmental index at 64 for age equivalent of 35 months. The psychologist agreed that he was somewhat difficult to engage. When he was frustrated, he hit himself. His seemingly imaginative play was actually very "scripted". He did seek the parents for play so there were some interactive skills. In summary, the team felt that he did demonstrated mild features on the autism spectrum, although he does show some interactive skills and empathy. On the other hand, he was perseverative, from his language description, and it was difficult to get him to interact on request. Recommendations were as follows: DNA test for fragile X. Admittedly, theh yield was not very high on this testing but important to rule out. The pt did have somewhat prominent ears. The main thrust of the recommendation was to continue with early childhood special education. Follow-up info was received on 10/06/2003 which pertained to events that occurred 2 years following the administration of MMR II on 11/29/1999. This info contained the following adverse experience: squint and rub eyes ([[name]] 2002). Autism was considered to be disabling. Upon internal review, body tremors and dyspraxia were determined to be other important medical events. Additional info is not expected. Medical records are attached as further documentation of the pt's experience.