Age: 13.0
Sex: M
Vaccine: DTAP
Symptoms: Immunoglobulin therapy, Laboratory test normal, Nerve root lesion, Neurological examination abnormal, Nuclear magnetic resonance imaging brain normal
Clinical narrative: Patient with a history of severe Guillain-Barre syndrome in August of 2011 following vaccination with the diphtheria, tetanus, and pertussis vaccine. Approximately 3 weeks prior to the onset of his symptoms, had 8 teeth that were extracted.  Treated with antibiotic prophylaxis and reportedly did well.  Approximately 2 weeks prior to the onset of symptoms, received DTaP vaccination, and 1 day prior to admission, complained of some upper respiratory congestion.  Was given Singulair.  The day prior to admission, started getting progressively weaker.  By the next morning, could no longer walk.  Taken to the Urgent Care and transferred to the Emergency Room and eventually hospitalized.  By Monday evening, was diagnosed with severe Guillain-Barre syndrome and started on IVIG.  CSF study 3 days into the course of the illness was reported as a normal study.  EMG done on August 10, 2011, showed a severe demyelinating process with some axonal involvement.  MRI of the brain and spine was normal except for nerve root enhancement in the cauda equina.  Received a 5-day course of IVIG, however, developed severe autonomic instability, profound weakness, eventually developed aspiration pneumonia, and required clindamycin antibiotic treatment for the pneumonia.  Given the worsening clinical presentation, eventually underwent 5 courses of plasmapheresis.  With the plasmapheresis, made a gradual recovery.  Was transferred to Rehabilitation on August 29, 2011, and was eventually discharged home on September 9, 2011. Patient is now back part time in school.  Is tolerating it very well.  Is continuing Rehabilitation 3 days per week.  This is scheduled to last for 12 weeks.  Is struggling with gaining weight.  Has only gained 3 pounds since discharge from the hospital, although patient is assiduously following the recommendations of Nutrition prior to discharge and is getting approximately 2600 calories per day. ALLERGIES:  NO KNOWN DRUG ALLERGIES. MEDICATIONS:  Slowly being weaned off Prozac.  It is currently 20 mg every other day. PAST MEDICAL HISTORY:  Severe Guillain-Barre syndrome in August of 2011. PAST SURGICAL HISTORY:  None. SOCIAL HISTORY:  Lives at home.  They have 1 dog.  There are no smokers. DEVELOPMENTAL HISTORY:  Attends Junior High.  In the 8th grade.  Just went back to school this week.  Doing fairly well.  Last year was a straight A student. FAMILY HISTORY:  It is positive for a history of migraine headaches, for a history of bipolar disorder and major depressive disorder, for a history of diabetes, for a history of a blood clot in the leg, and for a history of multiple sclerosis.  It is otherwise unremarkable and is available in the paper chart for review. REVIEW of SYSTEMS:  It was reviewed during the visit and is unremarkable except as noted in the history of present illness.  It is available in the paper chart for review. PHYSICAL EXAMINATION:  VITALS:  Height is 161 cm, which plots at the 40th percentile.  Weight is 37 kg, which plots at the 3rd percentile.  Head circumference is 56.5 cm.  Pulse is 99 and his blood pressure is 110/72.  GENERAL APPEARANCE:  Patient is very pleasant, very thin, who cooperates well with the examination.  HEENT:  Normocephalic, atraumatic.  The sclerae are anicteric.  The mucous membranes are moist and pink.  The neck is supple.  There is no lymphadenopathy.  The chest is clear to auscultation bilaterally.  CARDIOVASCULAR:  Regular rate and rhythm.  No murmur, rubs, or gallops are noted.  ABDOMEN:  Positive bowel sounds.  Nontender, nondistended.  EXTREMITIES:  No cyanosis or edema.  SKIN:  No neurocutaneous changes are noted.  BACK:  There is no evidence of scoliosis. NEUROLOGIC EXAMINATION:  Patient is awake and alert.  Cooperates very well with the examination.  CRANIAL NERVES:  The pupils are equal, round, and reactive to light.  Extraocular movements are intact.  There is no facial asymmetry.  There is no ptosis or droop.  Hearing is grossly intact bilaterally.  The uvula is midline.  The palate elevates symmetrically.  The sternocleidomastoids are grossly intact bilaterally, and the tongue is midline.  MOTOR:  Has 5/5 strength in both deltoids, biceps, triceps, wrist flexors and extensors, hip flexors, knee flexors and extensors, and plantar and dorsiflexion.  Tone is within normal limits.  DTRs are 1+ and symmetric at the biceps and brachioradialis and triceps.  They are undetectable at the patellae and the ankles.  The Babinski's are downgoing bilaterally.  Sensation is intact to light touch throughout.  CEREBELLAR:  There is no obvious dysmetria or dysdiadochokinesis.  Gait is intact.  Has no difficulty with toe, heel, or tandem walking. IMPRESSION:  Patient with a history of severe Guillain-Barre syndrome 2 weeks following a DTaP immunization.  However, other confounding factors included multiple tooth extractions 3 weeks prior to the onset of symptoms and upper respiratory infection- like symptoms the day prior to admission.  Fortunately made an essentially complete recovery.  Continuing to receive physical therapy and this is slated to last another 12 weeks.  Now back in school part time. Asks me what to do in terms of recommendations for future vaccinations.  I consulted the CDC, both calling them and going to their recommended web site.