Age: 12.0
Sex: M
Vaccine: MMR
Symptoms: Pharyngeal oedema, Pharyngolaryngeal pain, Pyrexia, Sinusitis, Skull malformation
Clinical narrative: Information has been received from a consumer concerning her 12 year old white son who on 8/14/97 was vaccinated with a 3rd dose of MMRII (lot 617553/0217D). In 2/98, the pt told his mother, "I haven't felt very good for a long time". It was reported that the child was evaluated for depression, at that time, but that "different doctors had different opinions as to the child's dx". His mother further reported that he had "problems with his legs that come and go", and that the child's current physician feels that the symptoms might be caused by a virus. It was also reported that the child is currently taking "low dose" prednisone. Follow-up information, received from a physician on 9/4/01, revealed that the pt is currently under evaluation for neuropathy and myopathy. It was reported that he is presently seeing both a neurologist and an endocrinologist, however, he is still in the process of being evaluated and "worked-up". The physician stated that they have not yet identified any etiology behind the neuropathy/myopathy, with the possible exception of hypothyroidism, which was identified in the child (timeframe/date unk) and which has been "corrected for a while". The reporter felt that there is "a possibility" that the neuropathy and myopathy are related to vaccination with MMRII, however, "cannot say this for certain". Additional follow-up received on 9/25/01, indicated that the physician was administered the vaccine was retired and that the reporting physician did not have any additional information. Medical records were received from the vaccinating physician's office on 10/16/01. The child was frequently seen between 11/4/97 and 5/14/98 and during this time, his complaints included vomiting, diarrhea, sinus inflammation and congestion, dizziness, throat swelling and irritation, abdominal pain, loss of appetite, cough, headache, fever and swollen glands. He was treated with various antibiotics, including Zithromax, Pen-VEE K, Vibramycin, Cefzil, Levaquin, Cedax, Ceftin and Dynabac. It was noted that the antibiotics caused him to have diarrhea but that when taken off them, his sinuses were a problem. He was also placed on various medications for symptomatic relief. The physician also questioned possible lactose intolerance. Further information received on 10/16/01 that he was seen by an allergist who did not find an allergic cause for the sinusitis and he was dx'd with staph aureus, by an ENT physician. On 2/23/98, he was seen by a gastroenterologist for left lower quadrant cramping and diarrhea. He was also seen by another physician who felt the child was depressed. He recommended starting Zoloft which he never received due to the fact that his mother was not satisfied with his care and changed physicians. Another physician dx'd him with Epstein-Barr virus by a blood test in 3/98. He was also dx'd with a candida infection and treated with Diflucan. On 3/9/98, the MD approved him for "homebound schooling", as he had been out of school since 2/98. He continued to have diarrhea and sinus drainage from 6/98 to 8/98 and was treated with Bactrim and clindamycin. At that time, a cobblestone appearance was observed in the back of his throat and he stopped talking, in approx. May. The pt indicated that he was able to phonate and articulate but that it "hurts too much to do so". In 5/98, the pt started to have lower extremity weakness and he became increasingly weak and his gait became shuffling and slow, by /98. On 7/13/98, he was seen by a Pulmonologist with additional complaints of fatigue and weakness. On 9/8/98, it was reported that "several weeks ago" he began to complain of leg stiffness and basically had become bed ridden for the entire summer and had difficulty getting on and off the toilet. On 9/4/98, he was seen in ER for neurological evaluation. The next day, he presented to another hospital for elective admission. It was noted that he would not move his lower extremities but was able to wiggle his toes. He complained of tingling in his left lower extremity and tone was markedly increased in all extremities but appeared to be voluntary muscle contraction. Infectious disease physician was consulted and he was started on Ancef, 1 gram IV q8h. The pt was treated with metronidazole 250mg tid. The pt was transferred to a psychiatric facility for inpatient evaluation. He was discharged on Lomotil 2 tablets po q8h prn diarrhea. On 9/28/98, he was noted to have a rash in his groin area and was placed on treatment with Tristatin cream and was taking Diflucan. He was put on Synthroid for hypothyroidism. On 12/5/98, a physician's order was written for a walker for 12 months. He started physical therapy again and was noted to have balance and equilibrium difficulties. Low back pain was improved. He reported having muscle twitches, at times. He had a "moon-type face". Slight kyphosis was noted. Trace mild edema was present. Hypothyroidism, EBV, Candida infection, cobblestone appearance of the throat, throat swelling and irritation, "stopped talking", enlarged liver and spleen, cold sensation and temperature intolerance, vomiting, diarrhea, sinus infection, dizziness, abdominal pain, loss of appetite, cough, headache, fever and swollen glands were considered to be incidental findings. Myopathy and neuropathy were considered to be disabling. Additional information has been requested. Follow-up info received from a physician on 11/30/01 indicated that the onset date of the pt's adverse events was 11/4/97. Follow-up info has been requested from the neurologist that is currently evaluating the pt. Hypothyroidism, EBV, Candida infection, cobblestone appearance of the throat, throat swelling and irritation, "stopped talking," enlarged liver and spleen, cold sensation and temeprature intolerance, vomiting, diarrhea, sinus infection, dizziness, abdominal pain and tenderness, loss of appetite, cough, headache, fever and swollen glands were considered to be incidental findings. Myopathy and neuropathy were considered to be disabling. Additional info has been requested.