Sex: M
Vaccine: LYME
Symptoms: Autoimmune disorder, Borrelia burgdorferi serology, Borrelia burgdorferi serology positive, Cognitive disorder, Contusion
Clinical narrative: This case was reported by a lawyer and described the occurrence of rheumatological symptoms in a male subject of unspecified age who was vaccinated with LYMERIX (GlaxoSmithKline). A physician or other health care professional has not verified this report. On an unspecified date the subject received unspecified dose of LYMERIX (unknown). According to the statement of injuries, at an unspecified time after vaccination with LYMERIX the subject experienced "joint pain and swelling, muscle pain, headaches, flu-like symptoms, possible memory loss, decreased activities of daily life". The statement of injuries also alleged that the subject experienced "rheumatologic, neurologic, and/or cognitive impairment of an autoimmune, immune-mediated, or other mechanism all caused by vaccination with LYMERIX including but not limited to those set forth above." At the time of reporting the outcome of the events was unspecified. Follow-up information in the form of medical records was received on 22 September 2008. An summary of examination dated 07 October 2004 mentioned the possibility of Lyme's disease, but was very vague. No specifics regarding testing or immunization with Lyme vaccine was noted. In the course of review of the medical records, an examination dated 03 July 2006 indicated that the subject was experiencing a flare in his osteoarthritis of the right shoulder. There was mention of a limited range of motion. On 09 November 2007, the subject underwent right total shoulder replacement. Follow-up visits dating through 16 Jul 2008 indicated that the subject was doing very well following surgery. An early examination back in September 2004 indicated that the subject was experiencing shoulder pain. Back in November 2004, the subject underwent arthroscopy of the right shoulder and debridement due to right shoulder osteoarthritis. The subject had been suffering from significant pain. The subject reportedly recovered well following the surgery. At this time, these events were just considered to be incidental findings as it is not clear how they relate to the claimed events. Follow up information was received on 03 November 2008 via medical records. On 12 and 19 September 2002, the subject reported foot and ankle pain since approximately May 2002, and was diagnosed with right ankle tendonitis and contusion. On 24 November 2004, he underwent arthroscopic debridement and lavage of the right shoulder due to osteoarthritis/degenerative joint disease, followed by physical therapy. The subject was evaluated by rheumatologist on 15 December 2004 for autoimmune disease, with osteoarthritis of the shoulder. He had "multiple questions whether this was related to the Lyme vaccination he had received in the past..." The rheumatologist questioned whether the shoulder problems were "more so related to multiple traumas in the past". He also had a remote history of cocaine use that the rheumatologist noted could be associated with avascular necrosis, although the subject had no history of this. The subject was evaluated in March 2007 for low back pain without a history of trauma, preceded by "sharp pain when he twisted which resolved quickly". Assessment included lumbosacral strain with spasm and/or sciatica. Treatment included ibuprofen and FLEXERIL. X-rays were notable for some degenerative disc disease. On an unspecified date, the subject was diagnosed with rheumatoid arthritis. Treatment included PLAQUENIL. When hospitalized on 09 November 2007 for shoulder replacement, he was reportedly receiving PLAQUENIL for hand arthritis. He was discharged on 10 November 2007, and required subsequent physical therapy through at least January 2008. The subject presented for postoperative total shoulder replacement follow up on 02 April 2008 and did not have full range of motion, although it had increased from his preoperative range. On 07 March 2000, the subject slipped and injured his back. In March 2000, the subject complained of occasional right buttocks and right lateral thigh numbness. Assessment included lower extremity radiculopathy, with decreased functional status and decreased range of motion.