Age: 51.0
Sex: M
Vaccine: LYME
Symptoms: Anxiety, Arthralgia, Carpal tunnel syndrome, Fatigue, Hypersensitivity
Clinical narrative: The pt works outdoors as a contractor. The pt received his 1st injection of Lymerix on 6/1/99. He was seen by his physician for physical exam on 6/20/99. At that time, he reported numbness of his hands in the morning. The pt was instructed to exercise and stretch his hands and wear wrist splints at night. During that visit, the pt received his 2nd injection of Lymerix and at some time later, the pt began to experience arthralgia and numbness of both hands. Early carpal tunnel syndrome was suspected and EMG tests were performed and interpreted as normal. In 7/00, a Lyme titer was negative and the pt was referred to a physician at a tertiary care center. On 9/15/99, the pt reported to his PMD that the consultant stated, "there was a 1 in 15 chance of the pt having a reaction to the Lyme vaccine." The consultant prescribed Vioxx. Prior to this, the pt had self-medicated with Motrin. The pt was seen by his PMD on 1/20/00 and at that time he reported experiencing arthralgia and numbness of his hands for 1 month. The physician's impression was "probably carpal tunnel syndrome" and the physician prescribed pyridoxine and wrist splints to be worn at night. The pt was seen again by his PMD on 9/15/00. The arthralgia and numbness of his hands persisted, and had extended to involve his shoulders. He had not been feeling well overall. The pt reported that his symptoms had begun after receiving Lymerix. He reported that a hot tub had been helpful in controlling his symptoms. He continued to take both Vioxx and Motrin. No swelling, stiffness or limited range of motion was noted on physical exam. The physician's assessment was recorded as "vaccination complications reaction (allergic), generalized anxiety, numbness, arthralgia hand and shoulder region, allergic rhinitis due to pollen." On 02/11/2002, in a statement of injuries, the vaccinee's attorney alleged that the vaccinee "has suffeed from debilitating joint pain and swelling in both wrists, hands and shoulders. In addition, he suffers from fatigue and amlaise." Outcome of the alleged were not specified. The adverse events "arthralgia" and "joint swelling" are being submitted as an expedited report.  A 15-day follow up report received 09/09/2003 adds: The pt returned to his primary physician on 11/18/2002 with a complaint of "pain in his left shoulder and left side of his neck which seems to radiate down the left side." On physical examination, the physician observed "no joint swelling or evidence of acute inflammation noted, however he does have tenderness on palpation of his left shoulder more in the posterior aspect and lower shoulder blade region. He also has pain with abduction of his arm beyond 90 degrees. His neck is supple but he does complain of some tenderness on palpation of the posterior cervical vertebra and rotation of his neck toward the right is uncomfortable." The physician made a diagnosis of "Arthralgia Shoulder Region" and ordered X-rays. The X-rays revealed degenerative disease of the cervical spine; please see Laboratory Data section. The physician referred the pt to a physical therapist. The pt returned to his primary physician on 02/04/2003. He reported that "Physical therapy was helpful somewhat in relieving his symptoms but he continues to have some pain, and is particularly concerned about numbness in his fingers bilaterally." On physical examination, the physician noted "tenderness on palpation of posterior cervical vertebrae." The physician also noted that the pt "still has some stiffness in his neck and paresthesias in his hands, especially with activity." The physician made a diagnosis of "Spondylosis Cervical, with Myelopathy". He prescribed dextropropoxyphene napsylate with Darvocet N-100 and referred the pt to his neurosurgeon. On 05/05/2003, the physician noted, "Overall (the pt) is doing well." The most recent info, received on 08/20/2003, did not provide the outcomes of the reported events. Info received on 06/23/2003 provided diagnoses of cervical arthritis and myelopathy as the reason for the numbness and the "debilitating" shoulder pain. As a result, this report has been reclassified as serious, unexpected. As of 02/04/2003, the neck pain, shoulder pain, and hand numbness persisted. The pt was "doing well" overall on 05/05/2003. The outcomes of the other reported events were not provided.