Age: 33.0
Sex: M
Vaccine: FLUN4
Symptoms: Erythema, Eye movement disorder, Eye patch application, Facial paresis, Flow cytometry
Clinical narrative: Patient was in a coma for this causality assessment and unable to speak with clinic; history obtained from patients wife, MD, and medical records. His wife stated he had been in good health exercising (run/lift weights) 6 days/week; and their 3 young children (ages 3 yo twins and 5 were healthy (no colds). According to his wife and review of medical records this 33 year old patient received his annual FLUMIST vaccination on 9/9/2013 (Lot # BH2026). Approximately 24 hours late he awoke with a non-productive cough and subjective fever. His wife said she could tell he didn't feel well. By 9/13/2013 (day 4) he complained of a headache with persistence of cough, subjective fever, and  profuse sweats. While he was able to go to work, he began to ease up on exercising. These symptoms waxed and waned without change until 9/27/2013 (day 18) when he became more lethargic, confused, with a weaving-upsetting gait holding wall with worsening headache, nausea, vomiting and a stiff neck (no pain) and numbness to bilateral fingertips. His temperature was 101F. His wife described his confusion as repetitive phone calls asking same questions; he would get up and begin to write being able to write he name then his handwriting was illegible. He would stop and lay down only to repeat this action on getting up and was writing over same marks trying to correct without success. He was taken to nearby ER on 9/28/2013 (day 19) where he was evaluated for possible meningitis. Exam: alert, not oriented, confused, rales left base with diminished breath sounds bilaterally, poor respiratory effort (20 bpm 97% 21/nc) skin erythematous with macular papular spots on lower extremities (chigger bites per wife). CT head showed edema and WBC showed leukocytosis with left shift. He was transferred and admitted to hospital where his MRI showed extensive changes consistent with inflammatory/infectious process (possible acute postviral encephalitis or PRES). CXR showed evidence of atelectasis. LP was performed following 1 dose of antibiotics (on vancomycin and ceftriaxone) On 9/29/2013 he appeared ill, was drowsy but would awaken to voice, oriented to name only, could not read room sign but did follow objects at distance; left leg>arm>face weakness; problems with two step commands, problems communicating...diagnosed multifocal leukoencephalitis. By 9/30/2013 his max temperature was 102F. He awakened to touch moving all extremities but was unable to speak. On 10/1/2013 he became obtunded, was unresponsive with posturing to upper extremities to pain and lower extremities withdrawing to pain. He was transferred to ICE and intubated and changed to a tracheostomy on 10/16/2013 for CPAP, secretion and airway maintenance. His trach was removed 11/8/2013. A ventriculostomy for decompressive purposes was required 10/1/2013 with ICP measurements peaking at 90 mmHG - his pressure was normal 10/15/2013 and the drain was removed. He received 5 plasmapheresis treatments with last treatment given 10/16/2013, and given broad spectrum antibiotics, antivirals, and IV steroids. (There was no documentation on use of IVIG). During his hospitalization he was treated for and diagnosed with: ADEM, healthcare associated pneumonia, respiratory failure, dysphagia, encephalitis with increased intracranial pressure, hypoglycemia and bradycardia. His condition slowly improved and he was transferred to rehab about 11/10/2013. Rehab 11/10/2013-12/11/2013: He had a slow gradual improvement in level of consciousness mouthing words to family/staff, purposeful movement left arm>leg with dysconjugate gaze and right side hemiparesis. As of 12/11/2013 patient is awake, alert, has good eye contact but wears eye patch and glasses due to diplopia, and answers questions appropriately speaking in 1-2 words sentences. On 12/7/2013 he was discharged home from inpatient rehab and will continue outpatient rehab. Wife reports continued slow improvement.