Age: 1.0
Sex: M
Vaccine: HEP
Symptoms: Staring, Tic
Clinical narrative: This case was reported by a lawyer and described the occurrence of neurological damage in a male subject who was vaccinated with hepatitis B vaccine (Engerix B) and or unidentified hepatitis B vaccine for prophylaxis.  On an unspecified date the subject unspecified dose of hepatitis B vaccine.  According to the legal complaint, at an unspecified time after vaccination with hepatitis B vaccine, the subject experienced "neurological damage" which was attributed to " cumulative mercury toxicity".  The following information was received via medical records.  The subject was vaccinated with hepatitis B vaccine (manufacturer unspecified) at approximately birth, one month of age, and six months of age.  The subject was also vaccinated with diphtheria and tetanus toxoids and acellular pertussis vaccine (Dtpa), Haemophilus influenzae type b vaccine (Hib), live attenuated poliomyelitis vaccine (Polio vaccine), and measles,mumps and rubella vaccine and strain not specified (MMR vaccine) for prophylaxis.  Medical history included allergies treated with ALLERGA.  The subject' s first words occurred at one year old, followed by slow expressive vocabulary growth.  He ceased us of existing speech at 19 month old.  At approximately the same time, he exhibiting staring episodes lasting approximately 30 seconds and occurring approximately 10 to 15 times per day.  In July 1992, right sided hearing loss was detected.  on 09 September 1992, the subject was evaluated for concerns about speech, high activity level, and difficulty responding to structure.  He was diagnosed with pervasive developmental disorder.  On 10 October 1992, the subject underwent an infant developmental evaluation for delay in speech.  Examination revealed hypotonia, cognitive functioning "significantly below normal level", language skills in the 6 to 7 month age range,a nd decreased social interaction including un sustained eye contact.  An eye examination was normal.  In a letter dated 22 August 1995, a physician stated that the subject was  "developing normally until the age of approximately 12 months when he reportedly received a DPT shot".  He reportedly experienced a reaction characterized by prolonged crying and inconsolability, followed by swelling of the leg.  According to the evaluating physician, "He was noted with a change in his developmental skills including staring episodes,a nd a decline in his speech and functional motor skills". Psychological evaluation on 19 April 1996 was performed for concerns including impulsivity preservation, temper tantrums, and non compliance.  Findings included average intellectual functioning for nonverbal and quantitative problem solving, and borderline functioning on tasks requiring verbal response and verbal reasoning.  Treatment included speech and occupational therapy.  Additional observations included parallel play, hyperactivity without aggression, and echolalia.  In August 1996, he was evaluated for increased frequency of staring spells.  He was admitted to the hospital on 19 August 1996 to rule out seizure and/or metabolic disease, and several staring episodes were observed without any associated electroencephalogram abnormalities.  He was discharged on 20 August 1996.  Problems in November 1996 included inattentiveness, impulsivity, aggression, and obsessive compulsive behavior.  On 20 July 1996, the subject's problem list included tic disorder, possible seizure disorder, autism spectrum disorder,a nd attention deficit disorder, facial twitching was observed.  In January and February 1999, the subject remained essentially nonverbal with weak reasoning and short-term auditory memory.  Achievements in reading, math,a nd written language were within the average range.  On 17 November 1998, the subject presented to the emergency room for questionable seizures and facial movements. On one occasion, he lost his balance and fell, with loss of consciousness for approximately two minutes.  Following a follow-up examination on 22 September 1999, the subject's neurological stated "I think he does gave a tic disorder, and I am not convinced that he has seizures". On 20 November 2000, Adderall was prescribed for behavioral concerns including increased activity and temper tantrums.  On 01 May 2001, the subject was evaluated for nonspecific encephalopathy, and was instructed to discontinue Adderall and initiate RITALIN.  By 04 June 2001, the subject was "doing better on RITALIN as for tics, but behavior "louder".  CONCERTA was initiated in June 2001; however, he experienced increased twitching and CONCERTA was discontinued.  In the spring of 2002, the subject exhibited increased facial grimacing.  In May 2003, a trial of Stratters was initiated, followed by an improvement in attention deficit disorder.  Concerns at that time included nocturnal enuresis. By February 2005, formal language testing revealed age appropriate receptive language skills, and slightly below age appropriate expressive and pragmatic language skills.