Age: 18.0
Sex: M
Vaccine: HEPAB, MNQ, TDAP
Symptoms: Lymphocyte count normal, Malaise, Metabolic function test normal, Migraine, Myalgia
Clinical narrative: The pt reported to boot camp on 8/18/08. He received his first set of immunizations on 8/20/08. Around 9/2/08 the patient began to feel ill (sore throat, headache, congestion, rhinorrhea, productive cough and possible fever). Several other members of the platoon were ill with similar symptoms. The pt reported to Sick Call on 9/19 to be evaluated for the above symptoms. Pt was afebrile. He was diagnosed with a URI; SIQ'd for 24 hours and treated symptomatically. The pt was evaluated twice on 9/23/08 for a two day history of right hip pain and left leg weakness. He also reported upper back pain. The pt did not report that he had bilateral hand tremors. The pt had stopped his cold medication (Tylenol, Mucinex, Cepacol, Pseudoephedrine) on 9/22/08 because he thought they might be causing his neurological symptoms, but he experienced no improvement. On 9/24 the patient's symptoms were worse such that the patient was using crutches to ambulate. The pt was seen on 9/25 for "near complete paresis of his left foot, right leg weakness and worsening back pain (T10-11)". The pt was transferred to ED. No cause was found for the pt's symptoms (see tests below). He was referred to neurologist (to be seen on 9/26). On 9/26 in the early am, the pt received his second set of immunizations. The pt was seen by his PCP at 1625 for a routine follow up. The provider noted that the pt had severe left leg weakness, right leg numbness, left foot drop, and grossly abnormal gait which was a significant change in status from the previous 24 hours. The pt was transferred to ED. VS: temp 99, 140/90, 85, 16, O2 sat 100%. The pt reported mild urinary hesitancy, a vague sense of constipation, continued "flu" symptoms in addition to the above symptoms. The pt was admitted for an LP and a course of "high dose steroids" for presumed transverse myelitis. Improvement was noted after 4 days and on 9/30/08 the pt was transferred to acute rehab with "significant weakness of the left leg, sensory changes to the right leg, mild to moderate depressive symptoms." The pt continued with oral steroid therapy. On 10/1/08 the pt began to experience migraine headaches. Based on the MRI of the brain (done on 9/30/08; see below) and CSF results the pt's diagnosis was changed to ADEM. The pt was transferred from acute rehab to another hospital on 10/9/08 with mildly decreased strength in the left leg, decreased sensation in the lower right leg, and migraine headaches controlled with IMITREX. The pt was started on MAXALT for migraine headaches. On 10/11/08 the pt was transferred (pt. utilizing a cane). The pt was seen in the ED on 10/11/08 for a reaction (rash) to MAXALT. 12/8/08 per PCP: " all deficits resolved and no further therapy needed". The pt's migraines are controlled with TOPAMAX 100mg dose. On 12/15/08 the pt reported that his left leg is slightly weaker than the right; he continues with intermittent, mid thoracic back pain (2/10) which occurs 1-2 times per week and lasts a couple of minutes before resolving without treatment. 12/30/08-records received for DOS 9/26-9/30/08-DC DX: Thoracic transverse myelitis. Presented to ED with progressive left leg weakness and right leg numbness. 12/26/08-records received for DOS 9/30-10/9/08-DC DX: acute disseminated encephalomyelitis. migraine headaches, resolved.