Age: 21.0
Sex: M
Vaccine: FLUN4
Symptoms: Tremor, Unresponsive to stimuli, Urinary sediment present, Urine bilirubin decreased, Urine ketone body absent
Clinical narrative: On 2 OCT 2013, 22 yo male received FLUMIST. His eyes watered and he felt the urge to sneeze immediately following vaccine receipt, but he did not experience other symptoms until approximately 60-90 minutes later. After approximately 20 minutes post-vaccine receipt, pt walked to dining hall within the hospital. Upon arising from the lunch table, coworkers said pt did not look well (expressionless, looking ill, out of it) and recommended that he sit somewhere cool. That was just prior to pt "passing out". Pt began falling, but a coworker caught him before he hit the floor. Patient was unresponsive with his eyes closed, and two coworkers described his movements as "shaking", which lasted approximately 5 minutes. Pt's eyes opened, but patient remained unresponsive. Pt was transferred by his coworkers to the ER. Pt does not clearly recall anything after leaving the immunization clinic until he awoke in a CT scanner, which is estimated to be about a 1 - 1 1/2 hour lapse. Pt remained "foggy" for several hours after leaving the ER. Pt's ER evaluation records from 2 OCT 2013 are not available except diagnostic tests below. On 3 OCT 2013, pt was evaluated by PCM. His physical exam was normal. (Pt reports during his neurological exam he was able to perform finger-to nose and heel-shin, but had to really concentrate, and he thought it took him an unusually long time to complete). A profile for no driving x 6 months was initiated and pt was referred to Neurology. On 11 OCT 2013, pt was evaluated a Neurologist. His physical exam, including thorough Neurological exam, was normal. Dr.'s Impression/Analysis: 21-year-old male with episode of altered awareness followed by apparent syncopal episode with convulsive activity and postictal altered awareness. His exam is unremarkable. Considerations include: 1. Seizure 2. Convulsive syncope 3. Concussion during the fall 4. Non-localizing examination. Although convulsive activity may be seen after a syncopal event, the altered mental status both before and after the episode argue for a seizure. Recovery from syncope would be more rapid once the pt was supine as well. Concussion could do the same if he had struck his head during the fall, but he was evidently caught before hitting the ground, and recalls no significant focal head pain or site of trauma. Pt was referred for ECG, echocardiogram, and Holter monitor, as well as an EEG - See Diagnostics. On 13 NOV 2013, pt followed up in Neurology. His physical exam was normal. His EEG results were reviewed. Per Dr.'s assessment: Essentially the patient seemed to be having a systemic reaction resulting in a syncopal event and secondary to this convulsive syncope. He has had no recurrence. The interval of his lapse of memory would be unusual for syncope but he had an episode similar to this lasting sometime approximately 1-1/2 months prior. These events could be representative of a transient global amnesia (TGA). Dr. questioned whether the OCT 2013 episode could have been related to receipt of the FLUMIST vaccine, but mentioned most (post-vaccine neurological) reactions occur within 2-4 weeks rather than within hours. Following his second Neurology evaluation, pt was returned to work without a profile. The following symptoms were reported > 12 months post-vaccine receipt, not at time of initial evaluations in OCT and NOV 2013: From approximately 1-2 days post-vaccine to 2-4 weeks post-vaccine, pt had problems with walking and feeling "unsteady". He had to concentrate to pick up his feet with each step - "It was like learning how to walk again." He moved slowly and often stabilized himself by holding onto the wall or railings. If he did not support himself, he felt "wobbly" and often had to "catch his balance". Although he did not feel weak, he had someone help him get up from sitting in a chair because he had difficulty getting up by himself. Also during this period, pt felt "clumsy with his hands". Around the time of vaccine receipt, pt started having tingling sensations in his fingers and toes. He thinks the tingling in his hands affected his ability to perform tasks with his hands, including some ADLs. He experienced problems manipulating the joystick to video games and he had problems holding a pen to write. Prior to OCT 2013, the movements were "automatic", but pt felt like he had to think about what his fingers needed to do. For instance, when he held a pen, although his fingers looked like they were grasping the pen, when he applied pressure to write, his fingers slipped down the pen and he was not in control of the pen's movement. The above problems with motor skills and coordination lasted about 2-3 weeks. Pt reports he continues experiencing intermittent, less intense tingling in his fingers and toes. More than a year after vaccine receipt and AEFI symptom onset, on 10 DEC 2014, pt was seen by Dr., Allergy/Immunology, for "concern for reaction to FLUMIST". At the time, pt's wife was concerned that pt might have experienced Guillain Barre Syndrome (GBS). A detailed history of his reaction following receipt of FLUMIST in OCT 2013 was obtained. Based on the history, Dr. determined pt had not experienced an IgE-mediated reaction to FLUMIST. Dr. referred pt back to Neurology to further evaluate memory lapses and possibility of GBS. She made the recommendation for a permanent medical exemption to Live Attenuated Influenza Vaccine (LAIV), but pending Neurology's assessment for GBS, recommendation for Inactivated Influenza Vaccine (IIV) was pending. On 21 JAN 2015, Dr., Neurology, re-evaluated pt considering concern for GBS. While GBS was not supported by pt's physical exams in OCT 2013, the possibility that pt experienced a mild post-vaccine cerebellitis was raised based on pt's reported symptoms of clumsiness and very brief cognitive difficulties. Although cognitive difficulties are not associated with cerebellitis, Dr. noted the cerebellum is thought to coordinate cognitive processes. Pt reports he was feeling well the day of flu vaccine receipt in OCT 2013. He denies recent history of respiratory or gastrointestinal infections at time of vaccine receipt. Pt denies experiencing rashes, dyspnea, wheezing, runny nose, cough, facial swelling, and GI-related symptoms within the first 8-12 hours of receiving FLUMIST. He denies a history of previous adverse events following immunizations. Pt denies any prior history of autoimmune or neurologic diseases. Approximately 4-6 weeks prior to vaccine receipt, pt reported a "lapse of memory" per AHLTA entry on 3 OCT 2013. PA-C noted: "lapse of memory from 1900 to 0430 about 5 weeks ago. There were not witnessed losses of consciousness during this time. States the last thing he remembers from that evening was leaving his friends dorm room. He apparently awoke the next morning in his dorm, in different clothing, and with abrasions on his elbows." During telephone interview on 27 APR 2015, pt described above episode to me as "spacing out" while he was driving home. Rather than going home after visiting a friend, he drove for 1 1/2 hours before his friend called him and he realized where he was, rather than headed home. He states he felt "weird". He denies a syncopal episode and drug or alcohol use. Pt has history of head trauma with multiple concussions resulting from skateboarding and Taekwondo-related activities. Pt's family history is negative for seizures, neurologic and autoimmune diseases. Currently, pt is able to carry out ADLs and perform his duties without problems. All above symptoms have resolved except for mild intermittent tingling in his fingers and toes. Pt did not receive influenza vaccine during 2014-2015 season.