Age: 17.0
Sex: M
Vaccine: MNQ, MNQ
Symptoms: Bradycardia, CSF test abnormal, Difficulty in walking, Gait disturbance, Guillain-Barre syndrome
Clinical narrative: Initial report received on 20Sept05. A 17 yr old male pt was diagnosed with Guillain Barre syndrome 1 month after he received a left arm injection of Menactra, lot number U1573AC on 15July05. He had symptoms of muscle weakness 2 wks prior to admission. He had an abnormal EMG and lumbar puncture. Follow up information received on 22Sept05. Hospital records were received for the pt. From discharge summary: 08/30/05 1:14PM the pt was admitted on 16Aug05 at 2PM and was discharged on 21Aug05 at 11:55AM. Bilateral lower extremity weakness secondary to Guillain Barre syndrome. The 17 year old male pt presented with bilateral symmetrical lower extremity weakness of spontaneous onset, progressively worsening over the course of 1 wk. He denied any recent trauma or febrile illness including upper respiratory infection or gastroenteritis. He first noticed having trouble going upstairs. Then his weakness worsened and he began to have difficulty going from a standing to a seated position as well as having gait abnormalities such as shuffling and wide based strides specifically. He denied extremity pain or paresthesias. He denied fever, chills, nausea, vomiting, sick contacts or diarrhea. He admitted to fatigue but denied shortness of breath, cough or dyspnea, tachypnea, headache or abdominal pain.  He did lose bowel control approximately 3 times over the weekend before admission, resulting in encopresis. The stools were well formed, not bloody or nonbilious. He denied urinary incontinence. He was evaluated by a neurologist and had an abnormal Electromyogram consistent with Guillian Barre syndrome. He was sent to the hospital for evaluation. ADHD, Asperger syndrome, no prior surgeries. Temp 99.8, blood pressure 138/92, pulse 134, respiratory rate 18, weight 200 lbs/90kg. Well developed, well nourished male teenager in no acute distress. Moist mucous membranes, normocephalic, atraumatic. Pupils equal, round and reactive to light. Neck is supple with no masses. Clear to auscultation bilaterally with no wheezes, rales or rhonchi. Regular rate and rhythm, S1 S2 heard, no murmurs, rubs or gallops. Soft, nontender, nondistended, positive bowel sounds. No visible rales or lesions. Extremities/musculoskeletal: no atrophy, speculations , full range of motion. Sensation was normal in all limbs and trunk. Deep tendon reflexes were absent. Strength is 4/5 at the upper extremities and 4/5 at the lower extremities as well. When asked to toe-heel walk he was unable to. Babinski sign was absent. He was alert and oriented x3. He was areflexic. Laboratory data: white blood cells 9.3, hemoglobin 17.1, hematocrit 48.8, platelets 212, sodium 138, potassium 3.9, chloride 105, CO2 28, BUN 11, creatinine 0.8 and glucose 94. Urinalysis showed pH of 6.5, specific gravity of 1.025 and trace proteins. Calcium was 9.7, albumin 4.3, globulin 3.1, total protein 7.4, total bilirubin 0.7, AST 29, ALT 22, ESR 7, INR 1.1, PT 11.7, PTT 30.0, magnesium 2.1, phosphorus 4.5, CSF protein 60, glucose 72, and colorless.  CSF was without white blood cells or organisms. CSF culture showed no growth. CSF Lyme test was pending.  Hospital course: The pt was never on IV fluids. He received a regular diet which he tolerated well. Cardiovascular. Pt systolic blood pressure was intermittently elevated slightly to the 140's and 150's. Diastolic remained normal. The pt denied any shortness of breath or chest pain throughout the hospital course. Increased blood pressure was thought to be due to either medications or disease related. Neurological. On admission the pt's legs were very weak. Strength was 4/5 and areflexic. He received 36 grams of IV. IG x 5 days without difficulty or reactions. On hospital day 3, he was walking better without pain. Strength was back to 5/5 but still areflexic in the upper and lower extremities bilaterally. He remained areflexic on discharge. He will follow up with outpt physical therapy. Psychiatric. The pt's Asperger and ADHD remained stable on his home medications. Discharge medications included clonidine, Thorazine, Adderall, Clorazil and Cogentin. From discharge summary 09/06/05 3:36PM. Physical exam: Neurologic: Awake, alert and oriented x3. Speech intact and fluent. Cranial nerves II-XII intact. Motor is 4+ out of 5 bilaterally deltoid and triceps. 4+ out of 5, 5 out of 5 biceps and grip bilaterally. 4 out of 5 hip flexion bilaterally, 4+ out of 5 knee flexion, dorsi plantar flexion bilaterally. Sensation normal. Deep tendon reflexes areflexic upper and lower extremity bilaterally. Toes downgoing. Gait mild to moderately unsteady, wide-based. Hospital course: The pt was admitted to general inpatient neurology service for evaluation and treatment of probably AIDP (Guillian Barre syndrome). The pt underwent lumber puncture which demonstrated elevated protein without other abnormal results consistent with Guillain Barre syndrome. Baseline labs were obtained which were within normal limits. Lyme titer was obtained and appeared to be negative. Given likely diagnosis, the pt was treated with IVIG 400 milligrams per kg per day for a total duration of 5 days. Current serial viral capacities were done along with IVIG therapy. The pt was placed on telemetry monitoring for arrhythmia evaluation. During the pt's hospital stay, his strength improved clinically and on exam. Vital capacities were all normal during his stay. Telemetry did not demonstrate any concerning arrhythmias. IVIG was given with toleration for the total duration of five days. On the day of discharge, the pt's strength, gait, and affect became improved. The pt was given a prescription in case he needed it. Physical therapy and occupational therapy saw the pt while in house and recommended outpatient therapy. Upon discharge, outpatient therapy was set up. Final diagnosis: post vaccination Guillian Barre syndrome.  PMH: ADHD, Aspergers Syndrome & depression.