Age: 42.0
Sex: M
Vaccine: FLU3
Symptoms: Hypertonia, Hypoaesthesia, Hyporeflexia, Hypovitaminosis, Laboratory test abnormal
Clinical narrative: A report was received from a non-healthcare professional on 7/12/04 concerning a 42 year old male vaccinee. Details of the vaccinees medical history were not provided. In November 2003, the vaccinee received an IM injection of Fluvirin. Approximately two weeks later, he began to experience symptoms of muscle cramping and weakness, described as MS-like symptoms. The weakness was described as moving around and has involved the legs and arms, not necessarily at the same time. The severity is described as cyclic in nature and varying over time since the onset in November 2003 from very little muscle weakness to more significant muscle weakness. All neurological examination to date, including but not limited to MRIs and physical examination have been negative to date. Infectious disease consults have ruled out Guillain Barre Syndrome. Further information is being sought. Follow up received 8/9/04 from the Neurologist: This 42 year old male vaccinee was seen by the neurologist on 1/13/04. He is a right-handed chiropractor by occupation. The vaccinees past medical history includes environmental allergies, long-standing anxiety and asthma. His medications include Flovent 220mcg twice daily and Singulair, which has now been discontinued. His anxiety has not been treated. Review of systems is negative for past history of vertigo, transient sensory or motor deficit, gait abnormality, optic neuritis, bowel or bladder dysfunction, Lhermitte's sign or diplopia. The vaccine received a flu shot in early December 2003. On 12/19/03, the vaccinee developed paresthesias involving the soles of his feet. These consist of a pins and needles sensation involving the right, greater than left foot; he then develops some numbness involving the right great toe. More recently, he has noted an ascending pattern to the paresthesias. They initially involved the posterior surface of his leg and thigh, but this has started to involve the anterior surface of his legs as well as the posterior trunk area up to about the T6 level. He denies a Lhermitte sign, associated weakness, gait abnormality and bowel, bladder or sexual dysfunction. He did report on episode of urethral burning, which as assessed by the neurologist as not related to his symptoms. Occasionally, he also notes a slight tingling sensation in the inferior orbital region as well as the bilateral median nerve distribution. The vaccinees evaluation thus far has included EMG/nerve conduction studies, which were essentially normal. There was no evidence of polyneuropathy or radiculopathy. Brain MRI scan without gadolinium showed no focal brain abnormalities. Lumbosacral MRI scan showed some minor degenerative changes only. Laboratory values included a low-normal B12 of 362, normal folate, thyroid stimulating hormone, basic metabolic panel and complete blood count with a sedimentation rate of 6 (although the neurologist states this is probably not accurate as the blood sat for more than 24 hours before the test was run). A comprehensive neurological examination was performed. Blood pressure was 136/72, pulse 64. Cognitive and cranial nerve exams were normal. Specifically, there was no evidence of an afferent pupillary defect, subtle inter-nuclear Ophthalmoplegia or disc pallor. Sensory exam was intact to all modalities. No sensory level was elicited. There was no tenderness to palpation or percussion over the spine. No muscle spasm was noted. Motor exam revealed 5.5 strength with normal tone in the upper extremities but slightly increased tone in the right lower extremity. Reflexes were 3+ in the upper extremities except 1+ at the triceps tendons and 3+ at the patellar as well as Achilles tendons. Crossed abductor reflexes and supra-patellar reflexes were present. Three beats of clonus were noted on the right side and two on the left. Abdominal reflexes were absent and Hoffman signs were mild. There appeared to be a Babinski on the right side. Cerebellar exam was intact to finger-to-nose testing, heel-to-shin testing and repetitive and rapid alternating movements. Tandem gait, Romberg test and gait were all normal. He did appear to have a very slight Lhermitte sign. Neck was supple. The reporter's overall impression was that the vaccinee has evidence of cervical myelopathy. The neurologist does not feel that this is related to his flu shot, although this certainly needs to be considered. The neurologist also doubts that his symptoms are related to a low B12, although it was thought he may improve with oral supplementation of 500mcg per day. The neurologist considers that this symptoms are related to a structural abnormality such as cervical stenosis or disc disease or a demyelinating process. Further tests have been ordered: Cervical MRI scan with and without gadolinium, brain MRI with gadolinium, median and tibial evoked potentials, sedimentation rate and C-reactive protein. The results of these tests will determine whether a lumbar puncture is necessary. Results of these tests will be sought. (OMIC) Follow up received 9/2/04: Results of further tests ordered were received. MRI of the brain, with contrast material, revealed no significant abnormalities. Median nerve and posterior tibial evoked potentials were within normal limits. Blood analysis for ESR, C-reactive protein and thyroid function on 1/27/04 were also within normal limits. Lumbar puncture on 6/8/04, showed no organisms and spinal fluid cell counts, chemistry and immunopathology were within normal limits, and negative for syphillus and Lyme disease. No further follow up is expected. There are no findings to support a specific final diagnosis for this man's symptoms, as reported.