Age: 74.0
Sex: F
Vaccine: LYME
Symptoms: Paralysis, Pneumonia, Pulmonary oedema, Quadriplegia, Red blood cell sedimentation rate increased
Clinical narrative: The pt was diagnosed with Lyme disease in 1989 and 1992. Since then she has had several additional tick bites. she has been treated with cortisone for Lyme-related arthritis. Prior to the adverse event, the pt was reportedly a very active woman, involved in aerobics, four-mile walks daily and a part-time job. On 2/7/99, post vax, pt experienced flashing lights from the sides of her eyes and thought she was having a stroke. the lights disappeared, but she then experienced flu-like symptoms for several days. She advised her MD of these symptoms. On 3/7/99, the pt received a 2nd dose. She experienced flu-like symptoms again. On 3/20/99, she started to feel weakness on her right side and had excruciating pain at the base of her skull, This was also brought to the attention of her MD. She was rushed to the hospital. It was determined that the symptoms she was having were the result of Lymerix. She was given an injection and then released. She had to literally be carried to her car and into her house. The attending MD at the hospital said the injection would wear off in several hours. Twelve hours later she was still not awake. An ER MD called and asked about her condition. The MD was told that the pt was sleeping and then awakened and still complained about a terrible headache and weakness all over her body. The MD thought something may have been overlooked in their initial exam and had her brought to the hospital via ambulance. Then was admitted for the night. Around 10:00 on 3/31/99, the headache again became severe and she was then experiencing paralysis. She was put on a stretcher and while on the way to ICU she reportedly coded in the elevator. Within 25 minutes she was mechanically ventilated. She was transferred to a second hospital for an MRI. Two days later she was dx with acute transverse myelitis. She spend about six weeks in ICU on a ventilator and then a tracheostomy and a feeding tube were inserted, which she still has today. She went back and forth from the hospital to a rehab center for the next eight months until she was discharged home on 10/20/99. She is confined to a wheelchair and requires 24 hour home health care. A 15-Day follow-up states the pt experienced paralysis throughout her body, her oxygen levels were determined to be low, while hospitalized the pt developed bed sores as well as pneumonia. She was readmitted with suspected pneumonia and bone infection resulting from the bed sores. The pt was discharged to home "under 24 hours home healthcare with a Trach tube, feeding tube, foley catheter and confined to a wheelchair. As of 2/1/01, the pt still required the use of the feeding tube. The most recent info received on 8/10/01, did not provide the outcome of the transverse myelitis. F/U the pt pad slow neurologic improvement. On 3/26/99, the neurologist noted that the pt had improved, she could move her left arm and leg and shrug her shoulders. By 4/3/99, she could wiggle her toes and on 4/4/99, she could wiggle the fingers of her R hand.On 4/10/99,she was noted to have fllaccid quadripaesis. On 4/17/99, rehabilitation medicine documented neurogenic bowel and bladder and quadriplegia. The pt continued to make slow improvement. Because her oral intake remained inadequate a percutaneous endoscopic astrostomy (PEG) tube was placed on 4/20/99. On 4/28/99 she was exhibited slight movement right arm, little more on left. On 5/12/99 she was able to lift her L arm off the bed. On 5/18/99, she was successfully weaned from the respirator ad was able to sit ia a chair. On 5/24/99, she was able to move her procimal upper arm and lift her L leg. On 5/26/99, the neurologist stated everyday has slow improvement. More shoulder shrug. Moving L arm horizontally. On 5/28/99 the pt was transferred from the tertiary care ctr to a rehab facility.On 6/15/99 medical records indicated that she was readmitted to the tertiary care ctr on that date due to episodic dyspnea and hypoxia with increased mucus plugging. The pt's attorney reported that in 8/99 she was admitted to the hospital with bone infection resulting form the bed sores. As of 2/1/01 the pt still required the use of the feeding tube. The most recent information rec'd 8/10/01 did not provide the outcome of the transverse myelitis. The pt was seen in the local emergency room on 06/02/2001 to have her foley catheter changed. Her family reported that the "Foley tube is green. States it's been green for one week." Bed sores were also noted by the ER nurse. A urine specimen contained a "small" amount of leukocyte ester, at least 300 mg/dL protein, "too numerous to count" white blood cells per high-powered fields, WBC's in clumps, 25 to 50 red blood cells per high-powered field. "2+" bacteria, "occasional" squamous epithelial cells, and Gram negative rods and Gram positive cocci. A diagnosis of urinary tract infection was made, and the pt was treated with Bactrim DS one tablet twice daily. Please note that the urinary tract infection was not reported as an adverse event due to vaccine administration, but was found during the course of review of the pt's medical records. Therefore, it is not listed as an adverse event." The most recent info received on 12/17/2001. As of 07/01/2001, the pt required the use of a Foley catheter. As of 10/24/2001, the pt required the use of a feeding tube, trach tube and wheelchair. Following the onset of transverse myelitis, the pt experienced urinary tract infections, acute paranoid schirophrenia, dehydration, insomnia, congestive heart failure, anemia, Clostridium difficilo related diarrhea/colitis, cough, and alergic rhinitis. These were not reported as adverse events due to vaccine administration, but were found during the course of review of the pt's medical records. Therefore, they are not listed as adverse events. Medicla records from the rehabilitation facility indicated thatt he pt was transferred from that facility to an acute care hospital for treatment of osteomyalitis. She was treated with intravenous antibiotics. She recovered and was transferred back to the rehabilitation facility. Despite persistently negative Lyme serology, the arithromycin therapy was continued. On 6/20/00, Suprax was added to arithromycin therapy. The pt returned to physical therapy on 7/03/00, for gait training. She was discharged from physical therapy on 10/05/2000. The therapist wrote,"pt continues to have limited function secondary to her condition. However, pt has made significant progress and is independent with some functions." The pt was evaluated by a speech therapist on 07/07/2000. The "pt presents with sponic speech due to tracheostomy." The therapist wrote,"pt received home care from October 1999 until January 200 which ended due to severe anxiety attacks and cnfabulation. Pt behavior has returned to normal and is now able to tolerate therapy. Family has obtained electrolarynx for pt to be trained on." Further "therapy not recommended. Pt pleased with speech using electrolarynx." On 08/02/2000, the pt reported that she was "doing well." She continued "doing well" no complaints on 02/07/2001. She was still taking arithromycin and cefixime for treatment of Lyme disease on 02/07/2001. The pt resumed physical therapy on 01/04/2001. She was discharged from therapy on 03/02/2001. The therapist wrote, "No significant progress with pt's functional status secondary to poor endurance. Unable to successfully stretch hip and bilateral heel cords secondary to inability to carry over stretching at home and pt's inability to assume supine position. Pt may benefit from pressure relieving ankle foot orthosis." The pt was seen by a gastroenterologist on 03/15/2001 because of "diarrhea for about a month." A stool sample collected on 02/09/2001 was positive for Clestridium diffiolle toxin. The gastroenterologist wrote, "my impression is clostridium difficile related diarrhea/colitis. The pt is to discontinue to Zithromax and the flagyl. She will begin Vancomycin 250 mg orally fours times a day for a minimu of two weeks. The lomotil use is to be reduced to be used only as needed every four hours for severe diarrhea." The most recent info received on 03/09/2002. As of 01/17/2002, the pt required the use of a foley catheter. As of 10/24/2001, the pt required the use of feeding tube, trach tube, and wheelchair. The follow-up states that x-rays performed on 08/18/1999 revealed anterior subluxations of C3 and C4 and C4 on C5 with disc space narrowing at C5-6 and C6-7. On 09/01/99, the pt told one of her physicians that the subluxations were "old." The pt also experienced fungal infection. Medical records form the rehabilitation facility indicated that cultures from sacral decubiti, obtained 08/13/99, were positive for "abundant Citrobactar species, moderate Klebsiells oxytoca, moderate Pseudomonas seruginosa, moderate methicillin resistant Staphylococcus aureus. Moderate Enterococcus. Triple-phase bone scan, performed on 08/17/99, revealed "evidence of probable sacral and possible pelvic osteomyelitis." August 1999, "for definitive cultures and institution of intravenous antibiotios." She was treated with intravenous vancomycin, tobramycin, and ceftazidime. CT of the pelvis performed on 08/25/99, revealed "findings within the lower sacrum and cocovx consistent with chronic osteomyelitis associated acute osteomyelitis is strongly suspected; acute osteomyelitis involving the posterior left ischium is also strongly suspected: early osteomyelitis of the posterior right ischium cannot be excluded." The pt was transferred back to the rehibilitation facility on 09/01/99. The osteomyelitis resolved and the intravenous antibiotics were discontinued on 10/05/99. The most recent info was received on 07/09/02. The most recent information received on 8/16/02, indicated that the patient required a trach tube as of 3/29/02.  ** Follow-up report on 9/26/02: Report A0323439A (formerly 2000008570-1) is a spontaneous case from an MD referring to a 74 y.o. female who received lyme disease vaccine (Lymerix) and experienced acute transverse myelitis. Add'l info. and medical records were received thru the litigation process. Prior to the adverse event, the PT was reportedly a very active women involved in aerobics, daily 4-mile walks, and a PT job. The PT expresses the NLA-DR2 phenotype. Medical history included acarlet fever as a child w/resulting sensorineural deafness, swelling of the hands and face since at least 1970, use of hearing aids (1978), tinnitus, labyrinthitis, varicose veins, xerostomia treated with electrostimulation (1984), anxiety and depression treated with alprasclam (1985), chronic amoxicillin therapy for an unspecified indication (1986-1998), small infraction of the left internal capsule, foot pain (1990), premature ventricular contractions (1990), hypokalamia (90), hypothyroidism (90), elevated cholesterol (90), elevated triglyceriden (92), polymyalgia rheumatics (92), increased platelet count (95), decreased red blood cell count (96), hypertension (97), and Helicobacter pylori infection. The PT received desensitization shots for allergies to house dust and mixed feathers (84). She had an allergy to penicillin manifested by rash and shortness of breath, and an intolerance to aspirin manifested by tinnitus. Surgical history included total hysterectomy and bilateral selpingo-oophorectomy due to cancer in 1964, unspecified reconstructive surgery of both ears, varicose vein stripping, and salivary gland removal. The PT's family indicated that the PT had bilateral auditory canal implants to treat sensorineural deafness. However, no radio-spague implants were observed on x-ray, and her hearing specialist only documented hearing aid use. In March 99, she had teeth extracted and had planned to have others extracted. Orthopedic history included a cat bite to the right thumb with damage to the flemor pollicus longus tendon, decreased thumb mobility, and intermittent hand numbness (1987), ostearthritis of the right thumb (1987), left thumb (1997), left second and fourth fingers (97), and left wrist (97); and spinal disease. "She experienced pain in both shoulders (88) treated with paraostamol/caffeine/butalbital (Fiofioet). She experienced pain in the right shoulder (92); the pain radiated down the right arm and right leg and was treated with pironicam (Feldone) and nop?? sodium (Anapron). A diagnosis of "diffuse ????? and DJD (degenerative joint disease) was made in 92, the PT was treated with dexecopyopoxyphane/paraostamoll (Darvocat-N 100), napxoxen sodium (Anaprox), nabumatone (Rolafen), and hydrocodone/paracetamol (Vicodin). In 1992, electromyelography and nerve conduction studies revealed C5-6 cervical radiculopathy and L5 lumber radiculopathy. X-ray of the cervican spine in 95 revealed "widespread demeneralization seen. There is significant degenerative changes with disc space narrowing at 5-6 and 6-7 and retroliathesic of C5 and C6 seen probably narrowing considerable the spinal canal at this level." X-rays performed on 8/18/99 revealed anterior subluxations of C3 on C4 and C4 on C5 with disc space narrowing at C5-6 and C6-7. On 9/7/99, the PT told one of her MD's that the aubluxations were "old". X-rays of the lumbosacral spine in 97 revealed "moderated to marked levoscoliosis of the lumber spine centered at L3-4. There is narrowing of all the interspaces with posterior spurs at L1-2, L2-3. There is sclerosis of the sygapophysoal joints at L4-5, L5-S1." After reviewing these x-rays in 97, the radiologi's conclusion was "Extensive degenerative changes of the lumbar spine." She experienced pain in both arms from shoulder to elbow, muscle weakness, and decreased range of motion (98), a diagnosis of cervical sprain was made and the PT was treated with paracetamol/hydrocodone (Vicodin). The PTwas diagnosed with Lyme disease in 1989 and 1992. She was bitten by 2 ticks in June 97. On 6/11/97, she reported to her MD that she felt her "joints aren't right". She was treated with doxycycline. On 6/23/97, she was seen by her MD for numbness in both legs. When she presented for treatment after receiving LYMErix, the MD noted a "strong" history of tick exposure. She was treated with prednisone, reportedly for Lyme-related arthritis, however, she was being treated by a neurologist. She had been initially referred to the neurologist for treatment of Lyme disease in 1998. Following the onset of transverse myelitis, the PT experienced osteopenia, urinary tract infections including one yeast infection requiring hospitalization, fungal infection, olitis media, acute paranoid achitophrania, dehydration w/one episode of associated hypercalcemia, sick euthyroid syndrome, insomnia, congestive heart faillure, anemia, Clostridium difficils related diarrhea/colitis, probable ilous, cough, allergic rhinitis, allergic conjunctivitis, and right ptosis. These were not reported as adverse due to vaccine administration, but were found during the course of review of the PT's medical records. Therefore, they are not listed as adverse events. Concomittant medications included prednisone 5 mg daily, conjugated astrogone (Premarin), an unspecified herbal preparation for the treatment of arthritis, and chlordiasepoxide (Librium) as needed. On 2/7/99, the PT received her first injection of LYMErix. She was above the maximum recommended age for immunization with LYMErix. On 2/7/99, while driving home from the MD's office, she experienced flashing lights from the sides of her eyes, and thought she was having a stroke. The lights disappeared, but then she experienced flu-like symptoms for several days. She reportedly advised her doctor of these symptoms. Initially the PT's attorney reported that the PT received her 2nd injection of LYMErix on 3/7/99. At the time of presentation to the emergency rm, that PT reported that she had received the 2nd dose of LYMErix on 3/15/99. When she was transferred to the tertiary care center, her family reported that the 2nd dose of LYMErix was administered on 3/10/99. Medical records from the immunizing MD, documenting the date of immunization, have not been forwarded by the PT's attorney. Her attorney reported that she experienced flu-like symptoms again. On 3/20/00, she experienced the sudden onset of aching and tightness of her chest, radiating up to her nook and then "downwards bilaterally". She also experienced "severe" frontal headache, "excruciating" occipital pain with radiation down the back, and weakness. A nurse in the local ER recorded the weakness as generalized, while an MD at the tertiary care center recorded it as right arm weakness. The PT's attorney reported that the PT brought her symptoms to the attention of her MD. However, the MD at the tertiary care center stated, "PT tried to self-medicate - did not ask for help." On 3/21/99, the headache persisted and the PT developed photophobia and progressive lethargy. Her attorney reported that "she was rushed to a hospital", the ER record indicates that her family drove her to the local ER on the morning of 3/21/99. Blood was taken for analysis, and electrocardiogram (ECG) was perfoemd, and the PT was treated with nalbuphine (Nubain) 10 mg and prometharine (Phenergen) 25mg. White blood cell (WBC) could was normal w/a decreased proportion of lymphocytes and an increased proportion of granulocytes (please see Lab data section for detailed results of diagnostic evaluations). Erythrocyte sedimentation rate (ESR) was elevated. Troponin I level was normal. The ECG showed sinus rhythm with "frequent premature ventricular contractures with ventricular trigeminy. Incomplete right bundle branch block pattern... Non-specific ST-T wave abnormalities. The ER MD considered the events to be "due to vaccine." The PT was sent home. The PT's attorney stated, "She has to literally be carried to her car and into her house by her family members." The attending MD at (the hospital) said the injection would wear off in several hrs. 12 hrs later, she was still not awake. An MD from the emergency dept. at (the hospital) called and asked about her condition. The MD was told that the PT was sleeping and then awakened and still complained about a terrible headache and weakness all over her body. The MD then said that perhaps something had been overlooked in their initial exam and had her brought back to the hospital via ambulance. When she returned to the ER, she complained of an occipital headache with radiation to the posterior neck and right arm weakness. It was noted that she had "1 x 0.5 inch healing would with redness, no drainage" on her right shin. It was reported that she had taken chlordiasepoxide and prednisone earlier in the day. The PT was hospitalized for neurologic evaluation. Upon admission, "she has a severe headache with ongoing photophobia and increasing lethargy. She is having difficulty swallowing", on neurologic examination, "Deep tendon reflexes were increased on the right upper extremity. The Pt was somnolent and did not answer appropriately to any questions. She had Bibinaki that were equivocal and she was very lethargy (sic)". The admitting MD's impressions were "Early CVA and I am concerned about extension. Also I am concerned about the possibility this may be an underlying meningitis that does thus (sic)has not been able to be diagnosed. Rule out drug induced confusion. Rule out LYMErix as an otiology." The nurse noted that the PT had full range of motion of her left extremities, but "decreased mobility of her right lower extrimity and her marked inability to move right upper extremity." The headache was treated with acetaminophen. She was also administered one aspirin daily. Red blood cell (RBC) cound and hematocrit were decreased. Computed tomogram (CT) of the brain revealed "small infarct of the left internal capsule." On 3/22/99, the headache persisted. The PT was administered one tablen of incataninophan/caffeine/butalbital (Floricet). Approximately 20 mins later, the PT was "becoming increasingly solnolent" and "had progressive hypoventilation." She was transferred to the intensive care unit. On the way to the unit, she experienced respiratory arrest and was incubated and placed on mechanical ventilation. A neurologist was consulted. At the time the neurologist examined the PT, she had a stiff neck. The neurologist's impressions were "Left IMCA stroke. Rule out bleed, CNS infection. CVA brain stem. Rule out upper cord lesion." The neurologist performed a lumbar puncture; the cerebrospinal fluid (CSF) contained no WBC, 3 HBC?, and elevated protein. After the procedure, the neurologist stated, "History suggests vasculitis as cause for prior signs and symptoms. Treated with prednisone. If red rate increased prescribe SoluMedrel (mythylprednisolone)." Magnetic resonance imaging (MRI) of the brain was ordered, but refused by the family because of concerns regarding supposed auditory canal implants. CT of the head revealed "A tiny are of low density in the left internal capsule... No mass or hemorrhage is evident. No interval change." Chest x-ray showed stelectasis in the right lung base and probable mild perihilar edoms(?). WBC count was elevated, with an increased proportion of granulocytes and decreased proportion of lymphocytes. Potassium, calcium, albusin, total protein, and albumin to globulin ratio were decreased. Globulin was increased. Antinuclear antibody (ANA) titer, total Lyme antibodies by EIA, Lyme IgG by Western blot, Lyme IgM by Western blot, Sjogren's SSA antibody titer, and Sjogren's SSB antibody titer were negative. Arsenic, ,mercury, and lead levels were within acceptable limits. Amounts of alpha-1, alpha-2, beta, and gamma glubuline measured by protein electrophorasis were normal: however, albumin was decreased. IgG levels were decreased; IgM levels were normal. No monoclonal protein was detected by immunofixation. Cultures of CSF, blood, and urine were negative. Sputum culture was positive for staphylococcus auraus. The PT was treated with albuterol (Proventil), ipratropium (Atrovent), and potassium chloride. That evening, the PT was "incontinent of green/clay color stool." On 3/23/99, the PT was noted to have green uring. It was noted that greenish stool was in the urine. Impression of a consulting MD was "Possible UTI. Possible Pyuria." The neurologist examined the PT and noted numbness and paresthesias of both arms and legs. She had right-sided muscle weakness and up-going toes. The respiratory therapist noted that the PT attempted deep breathing, but was "unable to generate any muscle power." The attending MD's assessment was "1) Progressive neurologic weakness - ascending paralysis - could this be Guillsin-Barro syndrom - atypical. Persistent hypoventilation - secondary to CNS insult. Neurology feels that this is a vasculitic cerabritis - such as lupus cerabritis. 2) Respiratory acidosis secondary to hypoventilation syndrom - suspect all due to neurology insult. Central hypoventilation syndrome." The PT developed "non-cardiogenic pulmonary edema." Chest x-ray showed "mild increased markings in the right lung base most likely atelectosis. Other consideration would include early infiltrate." CT of the brain, with and without contrast, revealed "1. Subtle hypodensity in the left internal capsule which may be due to a subtle infarot. 2. Sinus disonso." CT of the cervical spine revealed "Extensive degenerative changes of the cervical spine. No cord lesion could be demonstrated." The PT was treated with methylprednisolone 1000 mg intravenously, followed by 250 mg every 6 hrs, "without any significant improvement." She was also given one dose of famobidine (Pepsid) 20 mg intravenously. The PT was transferred to a tertiary care center for further diagnostic evaluation. Nerve conduction velocities (NCV) and electromyelography (EMG) performed at the tertiary care center on 3/24/99 showed normal motor conduction velocities in the arm and leg, right carpal tunnel syndrome, and right ulnar slowing across the elbow. No denervation was seen in the EMG of the leg muscles. CT of the head was performed, the radiologist's diagnosis was "Age appropriate volume loss with small vessel inchemic change. There is a vague lucency w/in the posterior limb of the left internal capsule which could be due to a lacunar infarct." X0ray revealed no radio-opaque implants in the auditory canals, no MRI of the cervical spine (with and w/out contrast) and magnetic reasonance arberiography (MRA) of the spinal canal were performed. The radiologist's diagnosis was "abnormal signal seen within the spinal cord from the cervical medullary junocion to C4-5 level. There is no abnormal enhancement post Cadolinium injection and finding likely represents inflammatory etiology such as acute transference (sic) myelitis. Degenerative spine disease... Vertebral arteries and carotid arteries are patent." Lyme antibody screen was "non-reactive". Antinuclear antibody titer was 1:40 w/a speckled pattern. Mothylprednisolone 1000 mg was administered intravenously every 6 hrs for 5 days. The PT then received intravenous immune globulin and a tapered course of methylprednisolong. She then received a tapered course of prednisone. She was also treated with famotidine, furosemide (Lasix), gualfanssin, albutoral, ipratropium, and subcutaneous heparin. On 3/25/99, the PT c/o'd of generalized pain. Her right side was flaccid and she had spasms in her right leg. Left side strength was reduced. The neurologist stated "MRI consistent with transverse myelitia (longitudinal) goes from C3 to T1." The PT spent approximately 6 wks in the intensive care unit. Her hospital course was complicated by difficulty weaning from the ventilator; central respiratory disorder w/lack of drive and Cheyne-Stokes like breathing; pulmonary edema, pneumonia caused by methicillin-resistant Staphylococcus sureus and Bactoroides fragilis treated with nebulised cobramycin, metronidaxole (Flagyl), and nearly 4 wks of intravanous vanconycin, which required peripherally inserted central catheter (PICC) insertion; tracheobronchitis and airway edema, severe trachaomalacia secondary to trancheitis; necrosis of the anterior trachear; Escherichia coli, Klebsiella, and yeast urinary tract infections treated with ciprofloxacin (Cipro), amoxicillin/clavulanate (Augmentin), sulfamathoxasole/tramethoprim (Bactrim), and fluconasole (Diflucan); chicken pox treated with ecyclovir; premature ventricular contractions, premature strial contractions; cachyoazdin while weaning from the ventilator, treated with diltiazem (Cardirem), artial fibrillation treated with digoxin, aphthous ulcers, anemia requiring blood transfusion; one episode of agitation and hallucinations; and persistent diarrhea. The PT made slow neurologic improvement. On 3/26/99, the neurologist noted that the PT had improved; she could move her left arm and leg and shrug her shoulders. By 4/3/99, she could wiggle her toes and on 4/4/99, she could wiggle the fingers of her right hand. The PT remained axeflexic, and on 4/10/99, she was noted to have flaccid quadriparceis. On 4/17/99, rehabilitation medicine documented neurogenic bowel and bladder and quadriplegia. The PT continued to make slow improvement. Because her oral intake remained inadequate, a percutanous endoscopic gastroatomy (PEG) tube was placed on 4/20/99. On 4/28/99, she exhibited "slight movement right arm, little more on left." On 5/12/99, she was able to lift her left arm off the bed. On 5/18/99, she was successfully weaned from the ventilator and was able to sit in a chair. On 5/24/99, she was able to move her proximal upper arm and lift her left leg. On 5/26/99, the neurologist stated, "Everyday has slow improvement. More shoulder shrug, moving left arm horizontally." On 5/28/99, the PT was transferred from the tertiary care center to a rehab facility. Final diagnoses were "1. Transverses myelitis. 2. Status post MRSA (methicillin resistent Straphylocaccos aurenal pneumonia. 3. Anemia." She reportedly "went back and forth from the hospital to a rehab center for the next 8 mts". On 6/15/99, she "was rushed back to (the) hospital w/a suspected case of penumonia." Medical records indicated that she was readmitted to the tertiary care center on that date due to episodic dyspnea and hypoxia with increased mucus plugging. These episodes "apparently responded to suctioning." One episode of low-grade fever was noted. Medications on admission included furosemide, digoxin, famotidine, gualfemesin, paporacillin/tarodactam (Zocyn), vanoumyola, magnesium oxide, multivitamin, mubeutaneous heparin and chlordiazepoxide 10 mg 3 times daily. At the time of this admission, the rehab MD's diagnoses were "1. Deconditioned. 2. Transverse myelitis with quadriparesis. 3. Acute pneumonia. 4. Status-post trach. 5. History of Orthostatic hypotension." The PT had persistent diarrhea. She had a stage IV secral pressure ulcer and bilateral stage IT lachoal pressure ulcers. She had thrush and aphthous ulcers. She was unable to talk, due to inadequate lung capacity to move the vocal cords. RBC, homoglobin, and hematocrit were decreased. Stool was ?? positive. On 6/16/99, duplex scan of the legs revealed "Probable small right knee effusion." Chest x-ray revealed "Moderate-sized bilateral pleural effusions with mild pulmonary edema." On 6/17/99, her WBC was elevated; the proportion of neutrophilo was increased and the proportion of lymphocytes was decreased. Potassium, protein, albumin, and iron saturation were decreased. Carbon dioxide was increased. Blood and urine cultures were negative. 2 stool samples were negative for Clostridium difficile toxin. Culture of tracheal aspirate was positive for moderate growth of methicillin-resistant straphylococcue aureus. Barium videofluoroscopic swallow study performed 6/18/99 demonstrated "delayed spiglottic inversion with aspiration w/thick and thin consistencies." There was "trace aspiration on thick liquid and moderate aspiration on thin liquids w/out ability to clear with cough." The pneumonia was initially treated with Zodyn and vancomygin. After culture results were rported, the pneumonia was treated with vancomvein and metronidezole. Respiratory acidosis was treated with aceterolamide (Iamox). Diarrhea was treated with acidophilus (Lactinex) and loperamide (Imodium). Thrush was treated with nystatin. Anemia was treated with a blood transfusion and ferrous sulfate. Docubis were treated with physical, then chemical/enzymatic, debridement. The PT's family reported that she was "very sleepy", so the chlordiarepoxide dose was reduced to 10 mg twice daily. On 6/25/99, the PT was transferred back to the rehabilitation facility. Discharge medications included loperamide, Lactinex, furosemide 20 mg twice daily, gualfencein 600 mg twice daily, albuterol and ipratroplum every 8 hrs, famodidine, multivitamin, vitamin C, zine, magnesium oxide, ferrous sulfate, digoxin, and chlordiazepoxide 10 mg twice daily. The primary discharge diagnosis was "pneumonia versus aspiration pneumonitis." The PT's diet was changed to "mechanical soft with some puddings. There was to be no thick or thin liquids." The PT's attorney reported that "In August 99 [she] was admitted to [the hospital] w/a bone infection resulting from the bed sores." Medical records from the rehab facility indicated that cultures from sacral docubiti, obtained 8/13/99, were positive for "abundant Citrobacter species, moderate Klebsiella oxytoca, moderate Facudomonas aeruginose, moderate methicillin resistant Staphylococcus aureus, moderate Enterococcus." Triple-phase bone scan, performed on 8/17/99, revealed "evidence of probable sacral and possible pelvic cateomyelitis". The PT was transferred from that facility to an acute care hospital on 8/23/99 "for definitive cultures and institution of intravenous antibiotics." She was treated with intravenous vancomycin, tobramycin, and ceftazidime. CT of the pelvis, performed on 8/25/99, revealed "