Age: 59.0
Sex: M
Vaccine: LYME
Symptoms: Arthralgia, Diabetes mellitus, Dyspnoea, Fatigue, Neck pain
Clinical narrative: The vaccinee reportedly received Lymerix; the number of injections administered was not reported. In a statement of injuries, his attorney alleged that the pt "suffers from joint pain in his hands, fingers, knees, hips, elbows and neck. He also suffers from fatigue, diabetes and asbestosis lung disease".  Following the reported onset of asbestosis, diabetes, fatigue, and joint pain, the vaccinee experienced hypertonia, parafoveal metamorphopsia, increased concentration of asparate sminotransferase, decreased concentration of testosterone, and leg cellulites requiring hospitalization. These events were not reported as adverse events due to vaccine administration, but were found during the course of review of the vaccinee's medical records. Therefore, they are not listed as adverse events. The vaccinee received three injections of LYMErix, the only injection documented in the medical records was the third injection, administered on 5/25/00(lot# not recorded). In a Statement of Injuries, his attorney alleged that the vaccinee "suffers from joint pain in his hands, fingers, knees, hips, elbows and neck. He also suffers from fatigue, diabetes and asbestosis lung disease." Time to onset following immunization was not specified.  The vaccinee was seen by a pulmonologist on 7/28/98. The pulmonologist indicatedt that he had reviewd records and reports from three physicians who had examined the vaccinee in 1997 and 1998. The pulmonologist noted taht during the vaccinee's employment, he "had extensive direct contact and airborne uprotected exposure to asbestos. He was also exposed in varying degrees to fly ash dust, welding fumes, nuclear radiation...and other occupational dusts and fumes....He has greater than twenty years of heavy asbestos exposure". At the time of the evaluation, the vaccinee reported that "he plans to stop working by December 1998 becuase of his breathing problems. (His) present respiratory symptoms are: Daily dry cough; shortness of breath at res, on minimal and on ordinary exertion, and very easy fatigability." Medication at the time of evaluation included Rexulin, Glynase, Glucophage, and ?. His height was 71 inches and his weight was 330lbs. Body mass index was 45.3; the pulmonologist recorded "severe overweight." The vaccinee was referred to a "specialist" by his employer. This physician evaluated the vaccinee on 2/17/99. In a questionnaire, the vaccinee described "shortness of breath on normal activity as well as while at rest. Co-morbidities include musculoskeletal pain in the cervial spine." Present complaints were recorded as follows. "He describes severe exercise intolerance with inability to climb more than one half flight of stairs. He has been morbidly obese most of his adult life. Respiratory symptoms include chronic dry cough, orthoapnea and amoring. He does not have any symptoms of hyperactivity. there is no sensitiration to cold, warm air, perfume or detergent. He has nonspecific irritation when exposed to diesel fumes." On 6/12/99, one of the vaccinee's physicians completed a disability determination form. the phsyician indicatedt hat he had last seen the vaccinee on 3/2/99. Treating diagnoses were listed as type 2 diabetes mellitus, hypertension, asbestosis, and carpal tunnel syndrome. Current symptoms were listed as SOB with activities. Pain in hands and neck." Medical hisotry was listed as chronic venous insufficiency with staiss dermatitis". Present symptoms were listed as "1) problems breathing - can't catch breath after 10 minutes of activity. 2) hands sore from carpal tunnel syndrome. 3) stiffness in neck." The physician stated that the vaccinee did not have neuropathy; "however patient has numbness and soreness in feet." The vaccinee applied for workers' compensation benefits on 6/17/99. He described his injury as "Lungs-asbestos lung disease. Long term exposure working with asbestos fibers and dust since 1961." He indicated that htis injury was reported to his employer, and an injury report had been filed. he indicated that he retired due to this injury on 11/1/98. On 9/1/99, the vaccinee underwent "disability evaluation with a history of diabetes, leg ulcer and silicosis. He was last employed 11/98 when he retired...after 57 years. He says he is being treated....for pulmonary silicosis and he has shortness of breath on moderate exertion. He says he must rest after walking approximately 100 feet on ground level. He is short of breath climbing one flight of stairs. he has a dry cough intermittently. He also complains of having no feeling in bottom of his feet. He has a history of diabetes mellitus since 1993...The claimant has a chronic ulcer on his righ tleg which he has been applying daily dressing to. The claimant states that the had some pain in his neck several years following an accident. he never received formal medical diagnosis or treatment but states that his neck has been getting progressivley less mobile over the years. At this time, he is unable to turn his head in either direction more than a very short distance." At the time of evaluation, his medication included ? 400mg daily, Dicvan 80mg daily, Glynase 3mg twice daily, Glucophage 500mg twice daily, and Augmentin 875mg twice dialy. On physical examination his height was 72 inches without shoes and his weight was 374lbs without shoes. It was noted that the point of maximal impuse of the heart was in the left fifth intercostal space. On examination of the extremeties, "there is a 2+ bilateral pratibial edema. There is also hyperemia at the anteriro distal aspects of both legs. There is approximately 3cm ulcer on the mid anteriro aspect of the right lower leg with no surroundings inflammatory signs. There are good dorsalis pedis pulses on the right. No pulses are detected on the the left foot. There are no varicosities. No muscle atrophy is evident. Musculoskeletal: there is limitation of rotation in each direction at the cervical spine to maxium of 15 degrees. There is no measurable flexion or extension at the cervical spine. There is a normal range of motion of the bilateral shoulders, elbows, wrists, fingers, hips, knees and ankles. Straight leg raising is negative bilaterally. No joint effusion or inflammation is appreciated." The physicians impressions were "1. History of pulmonary silicosis. 2. History of diabetes mellitus 3. Trophic ulcer, right lower extremity 4. Obesity 5. Derangement cervical spine. Prognosis Quarded. Imapaired for pronlonged standing and prolonged walking. Impaired for rapid neck movement and upward gazing. A variety of Lyme serologies were performed on 10/17/01. The laboratory's overall interpretation was "no evidence of seroreactivity beyond that expected from the Lyme vaccine." The most recent information received on 6/23/02, indicated taht the asbestosis and diabetes mellitus persisted as of 9/1/99 and were disabling. The outcomes of the fatigue and joint pain were not provided.   Time to onset following immunization, treatment and outcome of the alleged events were not reported. Asbestosis lung disease is considered "Medically Serious".