Age: 43.0
Sex: M
Vaccine: LYME
Symptoms: Joint swelling, Rheumatoid arthritis
Clinical narrative: This report describes the occurrence of chondrocalcinosis due to pyrophosphate deposition in a 43 year old male who was vaccinated with Lyme disease vaccine recombinant OspA for prophylaxis. This report was received as part of litigation proceedings, with forwarding of medical records. The subject's medical history included a sulfa allergy, other unspecified allergies, anxiety for which the subject was referred to a psychiatrist, multiple lacerations requiring autures, Raynaud's disease, elevated rheumatoid factor concentration (5/22/00), refractory purulent otitis externa (1987), papular rash treated with fexofenadine (9/2/00), dizziness and fever (treated with famciclovir, prednisone, and cefuroxime; 9/28/00), motor vehicle accident resulting in recurrent pain and numbness of the right thigh, low back pain (1992), "mild" spondylosis at L5-S1 with annular tears at L3-4 and L4-5, neck strain (1998), ulnar neuropathy (1998), tobacco use (two packs of cigarettes per day), and alcohol use (16 ounces of beer per day). Orthopedic history included fracture of the left third finger in childhood, torn meniscus in the right knee requiring arthroscopic surgery (1982), degenerative joint disease of the left first metatarsophalangeal joint following an injury (1987), upper back and left shoulder pain (1988), right forearm tendonitis with "creaking" in the forearm tendons (1989), right knee pain (1990), unspecified injury to both hands (1992), "huge" lateral meniscal tear in the right knee requiring resection (1995), degenerative joint disease of the right knee (1995), "small" tear of the posterior horn of the medial meniscus in the collateral ligament (1997), "small" popliteal cyst in the right knee (1997), and shoulder tendonitis (1998). His orthopedic surgeon prescribed a brace for the right knee in 1996; by 1998, he wore the brace "constantly." Social history included working as a carpenter and playing amateur baseball "and many other sports." Family history was significant for an aunt with rheumatoid arthritis. Concurrent medications included Daypro, Allegra and Augmentin. The subject received injections of LYMErix on 6/21/00m 7/21/00 (lot LY146A9), and 7/19/01. His attorney alleged that, after 7/21/00, the subject "experienced fatigue, weakness and joint pain in his knees, shoulders and hands. As such, he has been left to suffer with what has thus far been incurable and at times debilitating pain which severely limited his employment options and opportunities." The following info was obtained from medical records. The subject presented to the vaccine provider on 12/13/00 because "This morning strained left hand putting it in pocket." On physical examination, the physician observed "normal ROM wrist and elbow. No swelling. No local tenderness. Increased pain with extension and abduction of shoulder." The physician's assessment was "left arm pain-no pathology at wrist, forearm or elbow. Flexopathy?" The physician prescribed Relafen. The subject remained under the care of the vaccine provider until at least 3/26/02. The vaccine provider referred the sujbect to a rheumatologist. The subject was evaluated by the rheumatologist on 1/2/02. At that time, the subject was "complaining of swelling of the hands which is worse following any prolonged activity or after working. He is haivng shuolder pain, as well. He is also noticing easy fatigability. Morning stiffness= 20 minutes. No nodules or other extraarticular manifestations of RA are reported. His pain is relieved with Aleve." At that time, the subject reported a history of "gouty arthritis." On physical examination, "There is mild synovitis noted at the mcp's number 3 to 4 right greater than left, pip's number 2 to 4 bilaterally and at the right knee. Crepitus is noted at the right knee. There is full ROM throughout the peripheral and axial joints. No spinal tenderness is noted. Decreased sensation is present on the right thigh in an L4 distribution." The rheumatologist "aspirated the right knee off 1cc clear then bloody, increased viscosity fluid, which under compensated polarized light microscopy revealed 0 to 5WBC/HPF and intracellular CPPD." The rheumatologist wrote, "Rather than Ra, I believe that the subject has CPPD as a cause of his arthropathy. The presence of hyperviscous fluid suggests hypothyroidism, although I suspect that the CPPD is due to DJD. While the subject is concerned that the LYMErix mya have caused his arthropathy. I doubt this is the case." The rheumatologist recommended continuation of naproxen therapy. The subject remained under the care of this rheumatologist until at least 7/18/02. On 3/7/02, the rheumatologist wrote, "It is unclear if the subject has CPPD with a polyarticular "rheumatoid" presentation, or if he has CPPD secondary to RA." The rheumatologist discontinued naproxen therapy and prescribed Relafen. On 5/16/02, the subject reported "significant pain in the fingers, wrists, knees, hips and shoulders. This is wrose in the mroning. Morning stiffness= one to two hours. The hands continue to swell." On this date, the rheumatologist made diagnoses of "polyarthritis; chondrocalcinosis due to pyrophosphate crystals." The rheumatologist wrote, "The subject continues to have active synovitis. HIs x-ray is surprisingly normal, with changes noted only at the left third digit, where he reports he had a fracture as a child. I suspect that he has both RA and CPPD, but again, I cannot exclude that this is either the polyarticular form of CPPD or CPPD secondary to RA. Given the persistent synovitis, I will have him start Plaquenil, which is effective in both conditions." On 7/18/02, the rheumatologist noted that the subject "continues to respond favorably to his current regimen, with only minimal joint pain. There is vertually no swelling reported. He has been able to work, aggressively, without any discomfort." Medications at that visit included hydroxychloroquine and neproxen. The rheumatologist's diagnoses were "polyarthritis, condracalcinosis due to phrophosphate crystals." Following the reported onset of chondrocalcinosis due to pyrophosphate depostiion, the subject experienced an infected leg wound. This was not reported as an adverse event due to vaccine administration but was found during the course of review of the subject's medical records. Therefore, it is not listed as an adverse event. The most recent info, recieved on 4/22/03, indicated that the polyarthritis and CPPD persisted as of 7/18/02. At that time, the subject was "able to work, aggressively, without any discomfort." Follow up on 10/20/2003: "The most recent information, received on 09/30/2003, did not provide outcome of the events."