Age: 2.0
Sex: M
Vaccine: DTAPHEPBIP
Symptoms: Hearing impaired, Irritability, Malaise, Masked facies, Middle insomnia
Clinical narrative: A few days after the shot, he started to wake in the night crying as if in pain and he was inconsolable.  He has always been a good sleeper and had previously slept 12 hours a night without waking.  Now he wakes almost every night.  He had dropped his naps, but now needs a nap almost every day.  His cheery disposition is now grumpy.  For the first month after the shot, we kept saying that he just wasn't his usual self, that he was a little bit off, the he looked and acted as if he didn't feel well.   Then we started to notice that his clear words were gone and it was difficult to understand him.  He was slurring the first and last sounds of phrases together like "Floff" for "Fall off".  We also realized that he was not parroting our words like he had around his 2nd birthday.  He stopped bringing us books to read and didn't want to look at books anymore when we initiated it.  During the day, he would often cry and grab at his eye, one or the other and sometimes both, and he would cry and indicate that he wanted me to look at it, kiss it, make it better.  This happened often for a while and now every so often.  He has become clumsy, falling down, knocking things off of the table, and bumping into things.  He stopped answering us when we talked to him.  He stopped listening and obeying.  He doesn't seem to hear us.  From a distance, he will look at us, but one of his eyes is a little bit off.  Up close, he will not make eye contact.  He looks at us out of the side of his eyes.  He used to look at me and talk with me when I changed his diaper, dressed him, washed his hands, but no more.  When I tell him to look at me, he tries, but it is only for a few seconds and then he looks away or scrunches up his face with his eyes closed as if it is very uncomfortable to do it.  He was an easy going kid.  Nothing ruffled his feathers.  He took everything in stride.  Now he gets upset if things are not just so.  Noisy, busy places scare him.  He wants the tags cut out of his shirts.  He cries and says "hurt" when I cut his fingernails.  As of 8/19/09 he will not even let me cut his nails anymore.  He ran a high fever on 8/9/09 and things got worse.  We started to notice that his body would suddenly jerk and he would stumble or fall and cry.  Feeding time has become a stressful event.  He is refusing healthy food that he previously enjoyed.  Looking back at videos taken in the past two months, we noticed that he has been shaking his head and scrunching up his face for a while.  He took a 3 hour nap on 8/20/09 and woke up with a fever.  He ran the fever through the night.  On 8/21/09 he was inconsolable and could not nap because of the fever.  It dropped to 99.5 in the afternoon and he slept through the night.  He was a happy healthy child before the shot, and now he is very sick.  We took him to the doctor on 8/20/09.  She could see he wasn't the same child he was before.  Because of the sudden jerks and falling down, she referred him to a pediatric neurologist for testing.  He has an appointment on 9/9/09.  In the meantime, we are feeding him lots of whole foods and natural probiotics to try to boost his immune system. 8/28/09 Received PCP medical records. Records reveal patient experienced general good health on 5/14/09 visit for vaccination.  RTC on 8/20/09 w/irritability, waking at night, pulling ears, poor eye contact, hand flapping & intermittent staring spells.  Referred to Neuro.  12/29/2009 Neuro consult from 9/9/2009, patient with behavioral changes, balance and walking difficulty, jerking movements, loss of eye contact, verbal regression, night waking with pain, grabbing at the eyes, increased fatigue and irritability. Mother states in last 16 days after being started on the GAP (gut and psychology syndrome diet) some of these sx have abated. Dr ordered an EEG and CT head. EEG was wnl, no results of CT noted. No medication rx'd.