Age: 24.0
Sex: F
Vaccine: HEPA, JEV
Symptoms: Laboratory test abnormal, Malaise, Muscular weakness, Neuropathy, Paraesthesia
Clinical narrative: Service member went for training from June until August 2000. While she was attending training, she felt unusually fatigued. If an energy level of 100% is service member's baseline prior to June 2000, and a rating of 0 is bedridden due to lack of energy, patient rates her energy level while in training as level 10%. While there, she went home for lunch and napped. She went to bed shortly after her evening meal and she did not feel rested after at least 8 hours of sleep. At that time, she attributed her fatigue to the heat and the additional study requirements. (Service member found out she was pregnant in early June 2000.) While service member was at training, she began noting numbness and tingling in her hands and feet. After she returned home in August, these symptoms began to progress. Within two weeks of returning home, the tingling sensation extended to her calves and up to her hips and up her arms. Her muscles also felt weak. When she went for walks, she said her legs weighed a ton and she had to push her hips forward to get her legs to move. After sitting for more than 10-15 minutes, she felt too weak to get up. She was not able to hold her arms up to put in a pony tail. When the progression began, she sought evaluation in the clinic and was told that the symptoms were related to her sciatic nerve; later she was given a consult to neurology, but her appointment was not until October. In September, while doing Pregnancy PT, service member could not get up after doing exercises while sitting on the floor. She was taken to the hospital and after being evaluated, she was placed on 72 hours quarters and given an urgent neurology consult. By the time her neurology appointment, she had lost sensation in her face, she had lost her sense of taste, and she was having some burred vision and some problems swallowing. She also was experiencing some urinary incontinence. During her neurology evaluation she was told her EMG/NCV studies were abnormal, she had no reflexes, and the specimen from the lumbar puncture was consistent with Guillain Barre Syndrome. That same day she was admitted to the intensive care unit for observation and later, treatment. Patient recalls increased efforts to breathe, but never required assisted ventilation. After a few days of being hospitalized, she was treated with plasmaphoresis every other day, for a total of 5 treatments. Symptom: Paresthesia Comment: progressive numbness and tingling (ascending), Weakness Comment: ascending muscle weakness, Fatigue, Malaise > 60 days, Hyporeflexia Comment: absent DTRs per patient report, Sensation decrease: loss of sensation on face, Dysphagia, Blurred vision. Information from 60 day follow-up report states: 01/23/2006 Contacted patient by phone for update on status. She is essentially unchanged from our last encounter. She continues to experience muscle weakness and fatigue; no further evaluations or new treatments have been completed/inrelated by her PCM or Neurology. Recommended working with her PCM regarding evaluation of fatiuge to rule out underlying pathology like DM, anemia, hypothyroidism. Patient will be moving to another state in a few months.