Age: 38.0
Sex: F
Vaccine: RAB
Symptoms: Blood culture negative, Blood thyroid stimulating hormone normal, C-reactive protein normal, CSF culture negative, CSF glucose normal
Clinical narrative: After being exposed to a bat in her home, she received rabies vaccine #1 and rabies immune globulin on 23 Oct'11. She experienced no local or systemic reactions after these injections. She received rabies vaccine #2 on 26 Oct'11 and had no immediate local or systemic reaction. However, 3 days post vaccine on 29 Oct'11 she became lightheaded, dizzy, weak, lethargic and had tingling in the lower legs, forearms and hands and generalized joint pain. Symptoms gradually began to lessen. She received rabies #3 on 30 Oct'11. Symptoms had largely resolved by the time she received this dose except for intermittent dizziness. On 4 Nov, 5 days post vaccine #3, the previous symptoms came on suddenly and she again felt dizzy and weak. She also reports hoarseness started. In the evening muscle twitching began in the right pectoral muscle. She sought treatment at the facility and was put on quarters. On 6 Nov she received rabies vaccine #4. Symptoms again gradually began to resolve except for the twitching. On 7 Nov the twitching worsened and extended to the left arm and leg and right groin and right chest. There were no other systemic symptoms. On 10 Nov she sought treatment in the ER because of twitching symptoms lasting for hours and a feeling of "vibration" internally. Labs were done which were normal and she was released after being given 5 mg of VALIUM. "Fluttering', 'vibrations' and twitching continued and extended to the face, legs, neck, jaw, breast and axilla over the next few days. On 15 Nov she was evaluated by a neurologist. A normal physical exam was documented and an EMG/NCV was done which was normal. She was given BACLOFEN for symptoms: Diagnosis: Fasciculations: "Normal EMG and nerve conduction study. There is no evidence at this time of axonal denervation, myopathy, polyradiculopathy, or anterior horn disease. I was not able to capture any of the fasciculations during this exam. In spite of this but did visualize them yesterday and electrical identification of the fasciculations, in and of themselves, would not change the clinical picture. It remains to be seen the cause of these fasciculations and it may be purely a benign occurrence that will resolve on their own or may require the use of medications." On 18 Nov symptoms worsened and she felt a constant quivering in the legs which concerned her. She again went to the ER where the on-call physician was consulted. A spinal tap was performed and she was given ATIVAN 1 mg for symptom relief. Medications prescribed: ATIVAN, BACLOFEN, VALIUM: all ineffective for eliminating fasciculations. Current symptom update 7 Dec 2011, 31 days post rabies vaccine #4: "I am still having intermittent fluttering/twitches in various parts of my body to include my left inner knee, right outer knee, left upper arm near elbow, lower right calf and lower left calf. I sometimes feel off balance or just off. I had the "idle" sensation again all night Friday during sleep which made it difficult to get quality rest. My lower limbs still feel like they are vibrating on occasion. My head inside sometimes feels like it is "flickering". I have not had twitching in my right pec since the 30th. I definitely do not feel 100% but I do feel much better in comparison to the worst day which was the 18th."