Age: 2.0
Sex: M
Vaccine: FLU3
Symptoms: Gait disturbance, Hypersensitivity, Laboratory test abnormal, Ocular hyperaemia, Pyrexia
Clinical narrative: On 11/15/04 I received a telephone call from the patient's mother requesting information about the flu shot her son received in December of 2003 here at our health department. Her son received a flu shot 0.25ml, right deltoid, IM, on 12/12/03. According to the mother, one week later her son developed redness around his eyes and within 2 weeks of receiving the flu shot, rash occurred on his face and body. Mother claims no other symptoms were noted at this time. She took him to see the doctor on 12/24/03 and was told that her son was allergic to Dilantin that he took for his seizure disorder. According to the mother, her son was taken off of the Dilantin and started on a new seizure medication. The following day, 12/25/03, her son had multiple seizures. The parents contacted a doctor who was on call. The parents gave their son valium that they had at home. The mother told me that due to bad winter weather and the Christmas holiday, they did not take their son to the hospital until the following day. The mother told me that her son was hospitalized for 2 months. He was released to rehab where he was promptly admitted to ICU for respiratory distress. He was released the day before Mother's Day 2004.  According to the mother, her son has been a patient of several local pediatricians. The most recent doctor referred him to our health department for a flu shot. He was a patient of another doctor when he was first diagnosed with a seizure disorder after his third set of shots. The mother believes that those shots caused the seizures. The mother told me that the doctors do not know what caused the crisis for her son and that none of the doctors told her that the flu shot caused a severe reaction. She has scheduled an appointment with a specialist in vaccine reactions. She was instructed by another doctor to obtain the information about the vaccine and then file report online. The mother was not able to say if the report was the same as the VAERS. The patient is currently at home. His trach was reversed and he is breathing on his own. He can eat finely chopped foods, but continues to receive tube feedings. According to his mother, he operates at a 5 month level. He received PT, OT, and Speech therapies. I was informed he was being seen by a neurologist. The neurologist has declined to discuss the case at this time. 60 Day Follow Up: I phoned mother this afternoon and asked how her son was doing and what was the outcome of Dr's evaluation. Mother proceeded to tell me that pt has been evaluated by Dr's. Pt visits this group of doctors weekly for treatment. He will begin chelation therapy for mercury poisoning next week. The mother has believed right along that pt was suffering from Guillain Barre Syndrome and she stated that the doctor's are now thinking this too. Mother stated that pt's recovery has been slow and that he now operates at approx a 10 month old level. Last time she and I spoke mother said that pt was at a 5 month old level. He continues to be fed by G-tube and goes to weekly sessions for PT, OT and speech therapy at hospital. She said that the family is going to seek compensation to help pay for the treatments. Information from Discharge summary states fever, encephalopathy, respiratory failure.  Information received from Medical records state decreased vision, decrease in hearing, neurologicl regression, scarlet fever, edema of face, abnormal gait; stridor and irritability. msv Per follow up report-Patient's mother beleives improvement has been slow. Child does not "connect" to his environment and is not talking according to her. He started walking in May '05 and had the tracheotony removed. He continues chelation therapy at Dr's office. Since the start of the chelation therapy they have been able to decrease patients seizure meds and he appears more alert according to his mother.