Age: 54.0
Sex: M
Vaccine: LYME
Symptoms: Fatigue, Headache, Hypertrophy, Infection, Influenza like illness
Clinical narrative: On an unspecified date, the pt rec'd an injection of LYMErix; it was not known if he had rec'd previous injections of LYMErix. In a stmt of injuries, the pt's attorney alleged that the pt "suffers from joint and muscular pain. His muscular pain is primarily located in his arms and shoulders. He has arthritis in his R knee. He also suffers flu-like symptoms and he experiences fatigue. He also suffers from headaches and sinusitis. In addition, he has rashes on his limbs". Pt went to an ophthalmologist on 2/4/00. He reported that "for about 1 month when driving and watching TV, sees 2 lights coming together" He reported diplopia with far vision, but not near vision. He reported that he also " got the flu" and had " sinus pain". He reported that he "thought it was new glasses prescribed one month ago by another ophthalmologist. Notices w/o glasses now".  At that time, he was "recently off antibiotics." He was taking Celebrex, and Lescol. The ophthalmologist's impression was Mild esotropia times one month - no gross sixth nerve deficit. Chronic sinus disease and dental work now." The pt returned to the ophthalmologist on 3/7/00. He reported "diplopia a little less often. Happens more when tired "by end of day". He  also reported the diplopia was worse when driving at night. the ophthalmologist's impression was Small ET (esotropia) - possibly old now becoming more apparent/breaking down". the pt presented to his chiropractor on 2/8/00. On that date, the chiropractor made diagnoses of thoracic neuralgia and thoracic segmental dysfunction.  The pt remained under the care of this chiropractor until at least 1/31/02. During that time, the pt reported L sacroiliac and L buttock pain; central back pain after digging in his yard; lumbosacral stiffness;cervicobrachial pain after walking, cycling,and gardening; L arm pain with flexion; R sacroiliac and bilateral trapezius pain and stiffness; L orbital headaches; R knee pain; back pain after using chainsaw; bilateral trapezius and posterior deltoid soreness; increased back pain while supine; and frontal headache after working out, The chiropractor noted "palpable gluteus medius, L supraspinatus, bilateral infraspinatus, bilateral subscapularis, bilateral trapezius, bilateral levator scapulae, bilateral sub occipitals, and R quadratus  lumborum. He also noted locking of the following: C1,C2,C5,C6,C7,T1-T12,L1-L5, bilateral sacrum, and bilateral ilium. The chiropractor made dx of sacroiliac syndrome (3/21/00), subluxation complex (3/21/00), brachial radiculitis (9/5/00), shoulder tendonitis/strain (9/5/00), cervicobrachial syndrome(2/8/01), cervicalgia (2/8/01), thoracic spine pain (2/8/01), and sacroiliitis (9/20/01). The pt rec'd intra-articular injections of Hyalgan into each knee on 3/6/00, 3/13/00, 3/30/00, 3/27/00, and 4/3/00. On 4/3/00, the orthopedic surgeon noted, "He seems to be doing well". The pt underwent a physical exam by his employer on 10/4/00. at that time he reported "sinus headaches possibly caused by infection in tooth root draining into sinus. Double vision, general weakness, joint pain possibly from LYMErix vaccine". He also reported "Arthritis in knees and joints of hands, etc. Side effects from LYMErix vaccine. On 9/6/01, the pt was seen by another orthopedic surgeon with a complaint of right knee pain and activity limitation. the subject reported that he was able to walk about one mile, although "he has pain with every step". On physical exam, his right knee has a small varus deformity.. He has a 5 degree flexion contraction. He flexes to about 110 degrees with some pain and crepitation. There is no joint line tenderness. There is no AP or varus valgus instability. The right hip is full motion with no pain." The physician's impression was Osteoarthritis, right knee. The pt requested hyaluronic acid (Synvisc) therapy. He rec'd injections on 9/6/01, 9/13/01 and 9/20/01. Following the reported onset of arthritis, the pt experienced an adenomatous colon polyp, mildly enlarged L atrium, L ventricular hypertrophy, and L renal cyst. These events were not reported as adverse events due to vaccine administration, but were found during the course of review of the subject's medical records. Therefore, they are not listed as adverse events. the most recent information, rec'd 12/9/02, did not provide the outcomes of the reported events.