Age: 33.0
Sex: F
Vaccine: ANTH
Symptoms: Electrocardiogram ambulatory normal, Encephalopathy, Epstein-Barr virus antibody negative, Full blood count normal, Gait disturbance
Clinical narrative: This 33 year old patient received AVA #4 on 2/8/2012 approximately 0830am. Approximately 2100 hours (12 hr later) she developed a squeezing painful headache that radiated from bilateral temples down the back of her neck (was sitting - was unsure of meals that day and nauseated with headache. She also reported normal exercise of 30-45 minutes elliptical work earlier that day). Her pain scale maxed within 5 minutes of onset at 9-10/10. Concurrently she complained of a wobbly gait "as if drunk" requiring her to hold walls to maintain balance. She also stated she "felt clumsy as if she was moving in slow motion with the world around her moving fast". She advised turning her head caused pain and she wanted to keep her eyes closed (photosensitive). She reported she had never had a headache like this before. Her past headaches while weekly were mild 1-2/10 and typically triggered by workouts or skipping meals and would resolved quickly and without medical treatment. She reported to medical where she laid down and was given TYLENOL. Her symptoms eased about 2 hours later to 5/10 pain scale. However her headaches persisted unchanged (5/10) until 2/10/2012 when she and coworkers noted her speech was slurred her words seemed garbled and fuzzy with prolonged conversations as if tripping over her words. Her exam reported her actions were deliberate stating she had to think about what to do before completing a task, and she had problems with fine motor movements in hands - she could not touch her nose with eyes closed. By 2/13/2012 she correlated increased slurring of speech with severity of headaches. She was given diagnosis of possible Conversion Disorder verses possible MS like symptoms and was medivac'd for further evaluation. 2/12/2012-2/13/2012: Neurology documented complaints of headaches, weak jaw muscles, nasal congestion, slurred speech, ataxic gait, decreased sensation over right foot from a past fracture, and decreased oral intake. Her neurological exam was significant for increased symmetric reflexes (DTR 3+), wide based gait and mild decrease balance with stressed gait; otherwise normal exam. Diagnostic studies documented: CT head w/o contrast and MRA brain as normal; MRI brain showed mild mucosal and minimal thickening of ethmoid and frontal sinuses otherwise normal. Lumbar puncture was negative with no organisms seen in CSF culture or gram stain; CSF WBC 2, clear, colorless, RBC 9.0; protein 41.1, glucose 62with negative culture and gram stain, and Multiple Sclerosis Profile normal with IgG synthesis rate 0.3, no myelin basic protein or oligoclonal bands. Laboratory studies included negative RPR, Lyme, normal ESR, CRP, magnesium, phosphorus, TSH, FT4, PT/PTT, INR, CBC w/diff, and CMP except for low calcium 7.9-8.2, total protein 5.3-5.9, albumin 2.9, AST 10-13, and platelets 143-155. Nuclear Ab Screen and ANA studies requested new samples due to "possible interfering substances". There were no viral studies drawn. Her symptoms remained unchanged but stable and she was diagnosed with "headache, aphasia, and ataxia" (Feb 2012). 2/17/2012-3/7/2012 Medical Center: She complained of constant vise like headaches radiating from bilateral temples to back of neck (2-10/10). She treated with MOTRIN 800mg three x/day and prn use of TYLENOL 325-650 mg with variable relief. These headaches kept her awake at night. She described her speech as "sounding like she just had dental work"; and balance problems as tripping without preference to one side or the other, and worsening hand-eye coordination stating she would burn herself cooking and ironing. She did not drive due to motion sickness. Internal Medicine and Neurology exams documented: inability to protrude tongue, jaw muscle weakness, slurred speech, coordination and cerebellum abnormalities with slow finger to nose and some difficulty with RAM, balance impairment with absent Romberg's sign, wide based gait, and normal DTR. Neurology prescribed prednisone 80 mg daily x 7 days and stated the "acute onset with normal MRI and LP may be due to post vaccination encephalopathy". Diagnosis given were cerebellar ataxia presumed due to a central or cerebellar post vaccination process, and recurrent headache syndrome was "suspect due to rebound from NSAIDS". In March 2012, her headaches were improving being described as frontal pressure. She advised the short course of prednisone had significantly improved her headaches but they did return once off steroids. She reported associating episodes of increased heart rate with episodes of dizziness (described as floor moving too fast startled her) and increased heart rate when sitting still at home with headaches 4/10. Her Holter monitor 3/23/2012 documented NSR with no bradycardia. She had tachycardia (100-149 bpm) 32% time. No arrhythmias were detected. She currently drives short distances (<15 minutes) from home to medical office however she need to rest her eyes/head prior to moving once at destination. In April, 2012, she reported continual improvement in headaches with no medications needed x 2 weeks. She continued to experience some fine motor problems; however overall she reported improvement in coordination, dizziness, walking, and speech since working with physical and speech therapy. On May 15, 2012 she reported her headaches were only on awakening in the am and if overexerting herself. ADL's and work were "good". She is driving without difficulty. Neurology gave a diagnosis of cerebellar ataxia, suspecting vestibular origin with etiology suggested initially as proprioceptive origin (peripheral nerve or spinal cord) and then a mixed central and and peripheral. July 20, 2012 neurology documented continued vestibular rehab with improvements in dizziness and balance problems. She is working on walking tandem while looking side to side, and is 9 weeks pregnant and works full days at an administrative job. July-August 2012 she reported being about 60% back to her normal function and continues with vestibular rehab.