Age: 57.0
Sex: F
Vaccine: DTAP, LYME
Symptoms: Deep vein thrombosis, Erythema, Inflammation, Joint range of motion decreased, Joint stiffness
Clinical narrative: She had a history of tick exposure and regularly pulled them off her skin. She has not noticed any clear-cut ECM (erythema chronicum migrans) type of rash or experienced any of the cardiac or neurologic features of Lyme disease. The vaccinee described the onset of her joint symptoms as 9/98, when her husband hit the brakes in their RV (recreational vehicle) and she jammed the left middle and ring finger as well as severely injuring the thumb. "Things seemed to settle down" over a week's period of time" before she began bilaterally, which came on as she got older. The pt received estrogens conjugated/medroxyprogesterone acetate (Prempro). On 5/26/99 and 6/22/99, the pt received her 1st and 2nd doses of Lymerix, respectively. The pt reported that in 8/99 or early 9/99, approx. 6 to 8 weeks, after receiving the 2nd dose of Lymerix, she experienced a swollen left wrist. MRI, X-ray (NOS), and labs, including ESR and CPR were performed. The pt was told that her dx was "inflammation". Reportedly, her left wrist remained swollen for several months. In the spring of 2000, the pt's left knee swelled. Reportedly, the swelling then shifted to the right knee and then back to the left knee. Joint fluid was obtained 3 times. It "showed nothing". The pt was seen by several physicians and, subsequently, more lab tests were performed. Rheumatoid factor was found to be positive. At no time, did any of the pt's physicians suggest a link between her symptoms and Lymerix. Rheumatologist medical record of 3/21/00: In 9/99, while working on some stained glass, she noticed a "pop" and swelling in the left wrist. She has had a significant degree of pain since that time but that has gradually progressed and she was left more with stiffness. On 5/10/01, the pt's PCP reported that the pt's rheumatoid  arthritis began on 9/1/99, when she developed swelling and redness of the left wrist. Rheumatologist medical record of 3/21/00: In 11/99, the pt noticed muscle loss in the forearm. X-rays showed bone loss, and MRI showed inflammation. As of 3/21/00, the pt felt that she has been getting better and could now pick up a jug and use the arms and swing it at her side without as much pain. She described her pain level as slight. She denied any numbness in the hand or other joints which were "troublesome". She denied any significant low back pain. Peripheral exam: metatarsophalangeal joints were unremarkable. Knees: no fluid wave or warmth. Shoulder; full ROM; elbows, full ROM; right wrists metacarpophalangeal joints (proximal and distal interphalangeal joints) were unremarkable. She had 20 degrees of left wrist extension and 30 degrees of flexion and 80 degrees of right wrist. The left wrist was 2+ warm and 2+ swollen with 1 to 3+ tenderness on palpation. There was advanced atrophy of the left forearm muscularis. Lab tests of 12/7/99 showed ESR 37 mm/hr and Lyme titer was unremarkable although there was a single protein band of 41k. Assessment: monoarthritis affecting the left wrist. On 8/2/00, pt also had left knee inflammation when a physician aspirated and injected with steroid (NOS). Rheumatoid Factor was positive (40.1 IU/ml) and ESR was running in the 30's to 50's. Assessment: "We are probably looking at the early onset of rheumatoid arthritis." Celebrex was prescribed. On 2/01, Plaquenil was re-prescribed. On 4/6/01, the pt developed borderline hypertension. The PCP stated that the rheumatoid arthritis was moderate and possibly related to Lymerix. He also stated that the events could be associated with Prempro therapy. As of 5/9/01, the rheumatoid arthritis was ongoing and the blood clot in the leg had resolved. The outcome of the borderline hypertension was unknown.F/U she had no history of gout, psoriasis, crohn's disease or lyme disease. Her medical history included irritable bowel syndrome and duodenal ulcer. She had infectious thyroiditis in the 1940's. She had chronic rhinitis, hyperlipidemia, chronic anxiety,and chronic stress. She experienced left knee pain. Pt mother had arthritis, the rheumatologist reported that rheumatoid arthirits or lupus was not definitely dx'd in any family member. The pt rec'd chlordiazepoxide hydrochloride (Librax). 11/23/99 primary physician visit. The pt was seen for f/u on L wrist arthropathy. She had a normal uric acid leel on 9/9/99. she had been wearing a wrist brace intermttently but found that the swelling and pain would not let her tolerate wearing it too long so she went to an ace wrap. ahe has favored the hand for nearly 2 months straight now and feel that the muscles of the forearm are atrophying but the swelling was getting better. She has not had any loss of sensation in her fingettips as far as she knows. Physicial exam left had the wrist still had moderate effusion, no warmth, no erytherm. She is limitedin dorciflexion and plantarflexion by the swelling in the wrist, but she has good grip strength, finger abduction and finger adduction, she has normal two point discrimination in all five digits. There is atrophy of the flexor muscles of the forearm. Arthropathy imporving I told he pt I would like to do further workup, pt was very reluctant to do any further testing she wanted to just put ice on it and continue to wear the wrist band and do some exercises on the wrist. I explainedto her my concern about the permanent long term damage in the wrist joint and negotiated a referral to our orthopedic surgeon. 12/20/99 (orthopedic physician visit): there were not sighs of arthritic involvement of any joints other than the L wrist. She denies any other symptoms. Exam of the L wrist above a thickening and bogginess with slight erythema and induration. the ROM is almost normal, particularly with pronation and supination. Flexion and extension are slightly diminished. Grip strength is returning, but not yet normal. The mri reveals an inflammatory process. The assessmetn wa inflammatory procwss, left wrist, question lyme disease. treatmetn was a trial of anti inflammatory medication, such as ibuprofen and a wrist splint.