Age: 61.0
Sex: M
Vaccine: VARZOS, VARZOS
Symptoms: Muscular weakness, Myelitis transverse, Neck pain, Neurological symptom, Nuclear magnetic resonance imaging brain normal
Clinical narrative: Information has been received from a physician concerning a 61 year old male patient with hyperlipidaemia, a family history of "RA" and scleroderma and a history of hernia (twice) and tonsillectomy, who in December 2009, was vaccinated with a 0.65 ml single dose of ZOSTAVAX (Oka/Merck). Concomitant therapy included unspecified sleep aid and unspecified vitamins. It was reported that "few days after the shot" the patient started experiencing pain in neck and the physician called it ependymoma. Few days after the patient started experiencing reduced motor skills in his left hand and later in his left leg and also sensitivity area in the left shoulder. The patient was seen by another physician as well as by a neurologist. The patient was given steroids (name and manufacturer unspecified) and started feeling better around 10-JAN-2010. A magnetic resonance imaging  (MRI) was performed (results not provided). At the time of the report, the patient had improved about 75% (outcome reported as not recovered). Follow-up information has been received from a neurosurgeon, a neuro-oncologist and a neuro-immunologist via medical records concerning a 61-year old right handed male who worked in management consulting for the last 40 years. He is married, has 2 daughters with two herniorrhaphy, diet-controlled hyperlipidemia and a tonsillectomy. The patient denies significant family history of cancer; he drinks approximately 1 glass of wine per day. He denies tobacco or recreational drug use and any exposure to chemicals or toxins. The patient had a first degree relatives with rheumatoid arthritis (Daughter) and scleroderma (Sister). On 10-DEC-2009, the patient received a dose of ZOSTAVAX (Oka/Merck) after a regular checkup. Concomitant medication included multivitamin, aspirin and fish oil. He noted in 19-DEC-2009 and 20-DEC-2009, 2 episodes, 1 on each day of minor neck pain while lying in bed. This was not severe and no pain medication was needed. However, on 23-DEC-2009, when lying in bed he experienced an acute, severe and sudden neck pain, which lasted for about 15 minutes and stopped just like as soon as it had started. The following day, he noted numbness feeling in the left hand and arm as well as reduced motor skills. He could not put on shaving cream problems typing on the computer. He had definite numbness in the thumb and mild numbness in the other fingers of the left hand. He also noted on the following day a limp while he was walking, but without pain or obvious weakness. He also had minor neck pain. He took ADVIL with no significant improvement. On 26-DEC-2009, the symptoms continued, but he also experienced severe neck pain, which lasted for about 1 hour period of time and he also noted skin in the left posterior trapezius area to be very sensitive to touch. On 27-DEC-2009 to 30-DEC-2009, he noted that the symptoms of the left hand numbness and limping continued, but without intense pain. Because of the persistence, he went to visit his family doctor who requested neck, cervical spine x-rays as well as MRI scan. The symptoms continued and on 31-DEC-2009, he underwent an MRI of the cervical spine followed by an MRI of the brain. The MRI of the cervical spine reveals T2 hyperintensity within the spinal cord itself approximately C3-C4. The cord is not expanded. On the sagittal images, the lesion appears to be in the center of the cord. However, on the axial images, it appears to be at the left posterolateral aspect of the cord. It was well circumscribed. There was no significant surrounding edema and homogeneously enhances once gadolinium was administered and there appears to be no T2 change beyond the corresponding contrast enhancing portion. By report, the MRI of the brain was normal. He was referred to a neurosurgeon. On 01-JAN-2010 to 05-JAN-2010, he noted improvement in the lower extremity symptoms to the point where he was no longer walking with a limp and he had no pain in neck, but there was no change in hand symptoms. He had his first appointment with a neurosurgeon on 06-JAN-2010 and a full spine MRI was ordered. Also, a MEDROL DOSE PACK (6 a day) was ordered. Of note, the steroids were started after the most recent MRI was performed. (06-JAN-2010) and after spontaneous improvement in the lower extremities was noted. On 07-JAN-2010, symptoms continued again without a limp. Skin sensitivity in the left trapezius area ended and he was referred to a second neurosurgeon. This visit took place on 19-JAN-2010, at that time which is now approximately 5-6 days after the steroid treatment had ended, the symptoms became less intense specifically in the arm and he noted improvement in the functionality of the left arm and hand. Because of the relationship to the ZOSTAVAX, VALTEX was ordered. Over the last few days his symptoms have improved slightly. He has no neck pain and the VALTEX was cleared on 25-JAN-2010. The patient was noted that he has had near 50% or more improvement of the left upper extremity strength. Last night. He was able to type without difficulty on the computer while he admits he was not perfect. His strength was clearly functional. It was noted that the patient presented with neck pain and neurologic symptoms and a mild cervical spondylotic disease with degenerative disk changes al C3-G4, C4-C5, and CS-C6. The physician had a long discussion with the patient and family and his wide and reviewed the imaging studies, given the acuity of the presenting symptoms and timeliness related to the vaccine. The imaging findings included the lack of expansion of the cord and the lack of atrophy in the hands. The physician suspects that this was not a malignancy. The physician believed this was somehow related to the vaccine but cannot confirm that. It was also discussed with the patient the reason to do a biopsy would be only after complete medical management had failed. It was also not recommended a surgery given his symptoms have steadily improved over the last few weeks. The patient was referred to a neuro-oncologist to discuss further workup. On the consultation with the neuro-oncologist, the patient denies similar previous events or optic neuritis. He denies any recent southern hemisphere traveling other than September 2009, when he traveled internationally. He denies any fever, any preceding viral myalgia illness. He denies any tremor, any speech or swallowing difficulties, any headache, any vision changes, any hearing abnormalities, any changes in his urine or bowel pattern. Denies any ascending feel numbness or tingling. Denies any fasciculations or any change in the shape of his muscles. During the neurological examination the patient was alert and oriented x3. He had good attention and concentration. He followed simple and complex commands. He had no aphasia or right to left disorientation. Good immediate and delayed recall memory. His pupils were symmetric and reactive to light bilaterally. In the funduscopic exam, no disk edema bilaterally was observed. Extraocular muscles were intact. No presence of APD. No facial weakness or sensory changes. Tongue is midline. Palate elevates. Shoulder shrugs were symmetric. Hearing was normal to rubbing fingers. In the motor exam, normal bulk and tone, his strength was 5/5 throughout except for slowness to fine motor dexterity in his left hand. No pronator drift. Deep tendon reflexes, he had +3 and Hoffman in his left upper extremity. No Babinski, 3+ on his left lower extremity as well. No clonus, 2+ on his right side. There were no abnormalities to light touch or temperature. He does have decreased upper propioception and vibration in his left side. No cortical sensory loss to double simultaneous stimulation. The patient's coordination showed mild dysmetria on his left hand to finger-nose-finger, but due to weakness. No dindochokinesis. No tremor or abnormal movements. Finger-nose-finger on his right and heel to shin in both or his lower extremities were unremarkable. He was able to stand up and walked on tiptoes, heels and tandem without difficulty. Romberg was negative. The assessment from the physician was that the patient had a new left-sided mild motor and sensory symptoms which started about a month ago that had been improving dramatically even before steroids were given. In his neuro exam, it was found mild distal left hand weakness, hyperreflexia, and minor sensory deficits. His KPS was 100. MFS was 0, MSS was 0. His imaging has been reviewed. His clinical improvement and imaging appearance suggest a low yield for a cancerous etiology at this point. The neuro-oncologist determined that the patient had cervical myelopathy/transverse myelitis that needs to further worked up. Differential diagnosis included MS-like lesions, autoimmune due to his family history or infectious etiologies, the latter being less likely. it was suggested as a plan for the patient that he return to the general neurologist who should perform blood work and a spinal tap to look for the different etiologies. CSF cytology should be sent as well. The physician did not feel that this represent a neoplasm but he should be re-imaged in the near future. A biopsy would only be recommended if there is a significant change that suggests the lesion growing. He also should get a rheumatology appointment due to his strong autoimmune family history. On 24-FEB-2010, the patient reported to a neuro-immunologist that since early February, had numbness and paraesthesia involving the medial and dorsal aspect of his right upper extremity and his right leg. His neck pain has slightly worsened again. He complained of numbness and tingling in the fingertips of his left hand, slight tightness when making a fist, mild numbness in the right hand, electrical shock-like feeling on his right thigh and left torso lasting two or three seconds and occurring six times a day usually on sitting or standing, uncomfortable sensation suggesting allodynia on the right dorsal thigh when the patient is sitting. On his neurological examination the patient all the higher Cortical Functions, orientation, memory, attention, concentration, language, speech and affect were normal. His pupils were equal, round, and reactive to light. RAPD absent. Fundus normal bilaterally. Visual acuity 20-25 minus 1 right eye and 20-25 minus 1 left eye glasses. Color vision, visual fields, extraocular movements and pursuit normal. INO and nystagmus absent. Face symmetric with normal sensations. Hearing, tongue, palate, stemomastoid and trapezius normal. The motor exam was normal. The sensory exam showed pinpriok slightly diminished in loft upper extremity. Vibration slightly diminished in toes. His cerebellas exam was normal. Ambulated independently with normal toe, heel and tandem walk. Romberg sign was negative. Lhermitte's sign positive. Meningeal signs absent. The impression given by the neuro-immunologist was that the patient had a cervical partial transverse myelitis. The patient had partial transverse myelopathy which initially involved in the left upper extremity and caused neck pain but is now involving the right upper and lower extremities in a predominantly sensory manner. His cervical MRI showed C3-C4 hyperintense lesion with surrounding edema and enhancement seen both on the 31-DEC-2009 and 25-FEB-2010 MRI studies. Although the appearance on MRI was concerning a spinal cord tumor such as ependymoma or a glioma, the fact that his neurologic symptoms have improved and the temporal course of these symptoms would be somewhat atypical for a spinal cord tumor. Other possible etiologies include para-infectious post ZOSTAVAX (Oka/Merck) transverse myelitis (would fit the temporal course following ZOSTAVAX (Oka/Merck) vaccination on early December) versus CIS secondary to possible MS (given his cranial MRI imaging abnormalities). Additional workup is needed to be sure about this diagnosis and to recommend appropriate treatment. The recommendations were visual evoked potential studies to look for evidence of dissemination in space. A CSR examination will be done to look for evidence of inflammatory or infectious activity including VZV PCR and MS profile. More lab studies will be necessary looking for potential etioloiges including systemic collagen vascular disorders, nutritional deficiencies, etc. so it can be rule out remote possibilities of other causes. Depending on the results, it will consider either treatment with VALTREX for 10 days or IV SOLU MEDROL course for five days. The patient will also need follow-up serial MRI studies of the brain to look for evidence of dissemination in space and in time according to McDonald criteria. The patient will hold off on treatment with disease -modifying therapy at this time given that there was the possibility of this being a para-infectious transverse myelitis. It will be considered for the patient to received symptomatic treatment for his allodynia and hyperesthesia with NEURONTIN or LYRICA. The patient will return for follow-up at a later date to undergo the diagnostic studies suggested. He is to call in the interim if there are any new problems. Upon internal review cervical partial transverse myelitis, and possible multiple sclerosis (MS) were considered as other important medical event. Additional information has been requested. All available medical records will be provided upon request.