Age: 21.0
Sex: F
Vaccine: LYME
Symptoms: Biopsy skin normal, Blindness, Blood immunoglobulin G, Borrelia burgdorferi serology, Borrelia burgdorferi serology negative
Clinical narrative: This case was reported by a lawyer and described the occurrence of joint pain in a female subject of unspecified age who was vaccinated with LYMErix for prophylaxis. A physician or other health care professional has not verified this report. On an unspecified date the subject received unspecified dose of LYMErix (unknown). On an unspecified date after vaccination with LYMErix, the subject experienced joint pain, swelling, muscle pain, flu-like symptoms, fatigue, rashes, tingling in extremities, headaches, vision problems, shooting pains, weakness, insomnia, stiffness, numbness, vertigo, dizziness, possible memory loss, gastrointestinal disorders, sore throat, decreased activities of daily life, and rheumatologic, neurologic and/or cognitive impairment of an autoimmune, immune-medicated or other mechanism. At the time of reporting the outcome of the events was unspecified. This information was received via a Statement of Injuries. On 10 July 2007 medical records were received in the context of litigation. The subject reported that she received the Lyme vaccination in April and May of 1999. On 07 February 2006 the subject was evaluated by a hematologist and medical oncologist. Relevant history revealed a 22 year-old female subject who had been in excellent physical condition with high energy until 2000 when she developed symptoms of joint pain. She subsequently developed fatigue which was extremely unusual for her. In 2002, her symptoms became significantly progressive. She developed chronic neck and base of skull pain which was quite severe. No improvement following physical therapy. In January 2003, her symptoms became much worse with more fatigue. There were days when she was not functioning and was actually bedridden. She developed severe migraine headaches which often lasted for days. She also experienced arthralgias, intermittent rashes, paresthesias in her hands and feet and intermittently shooting electrical pains across her lower ribs and face. Changes in vision also developed that were often migraine related. She also experienced lightheadedness, temporary visual loss, frequent floaters and intermittent vertigo. A 10-15 pound weight loss in one year was noted. Intermittent night sweats experienced for past three years. Pain in her hips, knees and hands and trouble sleeping were reported. She reported that she was also evaluated by a neurologist and was treated with intravenous gamma globulin. Medical history relevant for asthma and environmental allergies. No family history of autoimmune disorders. Medications that the subject was receiving at this visit included albuterol inhaler, Allegra, Singulair, Lunesta, Vicodin, Migrani, Zomig, Phrenillin, Reglan and Plaquenil. She was diagnosed with chronic inflammatory demyelinating polyneuropathy, cause uncertain. He prescribed IVIG, Fioricet and Medrol. On 20 September 2006, the subject was seen by a neurologist. Findings were consistent with vascular encephalopathy cognitive impairment, small fiber neuropathy, and dysautonomia with interim improvement followed by IVIG therapy. On 08 January 2007, seen by neurologist for pressure and pain in the back of her head and neck, pain in the legs, sciatica and extreme fatigue. Findings were consistent with post-vaccination neurological illness, migraine, and cervicogenic headache, tick and Lyme exposure. On 09 February, she was evaluated by a hematologist and medical oncologist for pain in her neck, head and legs that is treated with Neurotin and oxycodone. The medications decreased the pain but does not control it. He noted that her chronic inflammatory demyelinating polyneuropathy appeared to be related to the Lyme vaccination.