Age: 25.0
Sex: F
Vaccine: RAB, RAB
Symptoms: Clumsiness, Computerised tomogram normal, Culture negative, Demyelination, Electrophoresis protein abnormal
Clinical narrative: "A 25-year-old veterinarian received the first two intramuscular injections of 1mL Imovax Rabies for pre-exposure immunisation on July 19 and Aug 3, 1987 (Merieux lot number Z0108, expiry date Feb 8, 1998. On Aug 11 she noted weakness in her right leg, followed by clumsiness with her right hand. She had had a brief shaking chill before the onset of symptoms. Neurological examination revealed mild weakness of the right arm, hand, and leg with right-arm and patellar hyperreflexia, and an equivocal plantar extensor response on the right. No cranial nerve, cerebellar, or sensory deficits were detected. A computerised tomographic (CT) scan was normal, but a single dose, non-delayed contrast CT study revealed a small focus of enhancement near the anterior horn of the lateral ventricle, and magnetic resonance imaging (MRI) indicated increased signal intensity in the periventricular regions bilaterally. Cerebrospinal fluid examination demonstrated: total protein 21.4 mg/dl with four oligoclonal bands, IgG/albumin ratio 0.545 (0.47 in serum), IgG index 1.1 (normal below 0.66), cultures negative for bacteria and fungi, myelin basic protein 1.1 ng/dl (normal). Her serum rabies antibody titer was above 0.5 IU/ml. Evoked responses were normal. Serum protein electrophoresis revealed a polyclonal increased in IgG (1800 mg/dl)." "Given the strong suspicion of an acute demyelinating process, the patient was treated with intravenous methylprednisoloen 1 g per day for 3 days followed by 2 weeks of prednisone. At the end of the course of prednisone only slight right anterior tibial muscle weakness remained. She remained symptom free for 10 months, after which mild right hemiparesis recurred, preceded by transient myalgia near the vaccination site. The weakness and right-sided hyperreflexia were identical to those seen in the first episode. MRI revealed several new areas of increased signal intensity in the periventricular regions plus similar lesions in the white matter of the cerebellum. She was again treated with methylprednisolone and prednisone, with neat-resolution of symptoms. Several months later optic neuritis developed with a Marcus Gunn pupil, which resolved spontaneously." "In this patient an inflammatory demyelinating process affecting the central nervous system (CNS) became symptomatic 8 days after a second dose of HDCV. The enhancing lesion seen on contrast CT suggests a vaccine-related inflammation/demyelination rather than multiple sclerosis. Although we cannot be certain that this woman's illness was induced by the HDCV, the systemic manifestation of her illness suggest that this is a reasonable possibility. Follow-up information received on 14 February 2007 from an author of the aforementioned literature article. Per the reporter, "over subsequent years, the patient followed a clinical course typical of relapsing-remitting multiple sclerosis." The event of demyelinating disease of the central nervous system was amended to relapsing-remitting multiple sclerosis based upon this new information. Additional medically relevant information was not provided. Following the reoccurrence of symptoms, "MRI revealed several new areas of increased signal intensity in the periventricular regions plus similar lesions in the white "matter of the cerebellum".