Age: 57.0
Sex: M
Vaccine: LYME
Symptoms: Migraine, Mitral valve incompetence, Myocardial ischaemia, Nausea, Sleep disorder
Clinical narrative: The pt received his 1st injection of Lymerix on 3/10/99 with no adverse experiences reported, post vax. He received his 2nd injection on 4/8/99. He was hospitalized on 10/12/99 with a chief complaint of vertigo. "The pt had started to get dizzy in the middle of September, was more lightheaded, especially while driving, it became intermittent. He was seen for the 1st time on 9/15/99, felt possibly to have vestibulitis, was tried on Antivert and it did improve. He called the office on 9/21/99, felt great, had no more lightheadedness or dizziness. He stated that he gets where he cannot navigate or drive...on the day of admission, when he woke up, it was very severe, he could not ambulate without being dizzy and lightheaded. The room does not spin around him and he does not spin around the room, however he cannot focus or navigate." The pt reported that "he does get occasionally nauseous. He denies any vomiting, diarrhea, melena or hematochezia. He denies any chest pain...he does feel like he is going to pass out, is usually worse in the morning and gets better during the day". On physical exam, the physician noted "no vertical or rotary nystagmus. There was some horizontal nystagmus...when he does stand up, he gets very dizzy...Romberg's is positive. There were no other focal or masses. Assessment: 1. Dizziness, lightheadedness, near-syncope, etiology to be determined." He was evaluated by a neurologist on 10/12/99. He was treated with Meclizine, with no improvement. He was seen in ER and since has had several episodes which were very brief. Romberg's test was negative. He was also evaluated by a cardiologist on 10/28/99. He was having some upper abdominal pains. He was also dx'd with "Myocardial ischemia involving the anterior wall, inferior wall as well as the inferior portion of the septal wall". He was evaluated by a 2nd cardiologist with complaints of some nausea, occasional emesis, chest discomfort, weakness, dizziness and various combinations of the above. He saw his PCP on 11/15/99 with complaints of "difficulty getting to sleep, feels anxiety and shakes when having episodes of dizziness, general malaise and pressure in chest radiates up esophagus". He prescribed lorazepam and Effexor. Then he started perspiring heavily and his temperature was 94/95F. He had occasional headaches. He is extremely irritable. On exam, the 2nd neurologist found that the upper limbs show mild postural trimmers. He has a strong family history of Huntington's disease, but tests show that he does not possess the Huntington's disease CAG mutation. Due to continuing headaches, he was  treated with Depakote for prevention of migraines. On 7/11/00, a specialist confirmed Lyme disease X 2 and prescribed Ceftin and Mepron and tapered off Depakote over 3 days. He reported to his PCP that he was still tired. He is receiving Malarone to treat the babesiosis. The doctor noted "some depression" and prescribed Paxil as well. On 2/11/02, in a statement of injuries, the vaccinee's attorney alleged that the vaccinee suffers from extreme lightheadedness, flu like symptoms, extreme chronic fatigue, and jiont pain in his shoulder. The most recent information, received 2/11/02, did not provide the outcome of the events. The most recent information, received 8/13/02, did not provide the outcomes of the events. Lyme disease, babesiosis, human granulocytic ehrlichiosis, panic attacks and migraine are considered persistently incapacitating because the pt was unable to work from 10/16/99 until mid-November, 1999. The follow up states further medical history of three "small" penticular cysts, "small" epididymal cysts, right shoulder pain (1984), neck pain, and "severe degenerative arthritis" of the ? The vaccinee experienced persistent right hand numbness following the right carpal tunnel release procedure. The follow up states further medical history of chronic flexor tendonitis left thumb (1997), mumford procedure for arthrosis of right AC joint (1996) and stiffness of the right shoulder for at least six months following the mumford procedure. The most recent info, received on 6/11/02, did not provide the outcomes of the events. **Follow-up report on 8/23/02: The vaccinee was evaluated by a family medicine MD on 6/10/00 for many complaints including fatigue, stomach problems, heart palpitations, headaches, neck stiffness, mood swings, and depression. On physical exam the MD noted that the vaccinee had an erythema migrane like rash at the base of the occiput erythematous sclarae, and "a very strong" sixth oxanial nerve palay, right greater than left. The MD's impression was: "1) Myalgia 2) Arthralgia 3) Cephalgia 4) Positive erythema migrane rash 5) Panic attack." He prescribed cefuroxine (Ceftin). Lab analyses performed from 6/13/00 thru 10/26/01 demonstrated abnormal results. Please see Lab Data section. On 7/10/00, after reviewing the results of serologies performed on 6/13/00, the MD made Dx's of babesiosis, human granulocytic ehrlichiosis (HGE), and Lyme disease. He prescribed Ceftin and doxycycline (Doryx). In a letter to VAERS, dated 8/3/01, he listed his impressions as "1) Babesiosis 2) Human Monocytic Ehrichiosis 3) Lyme disease, exacerbated by the Lymerix [sic] vax times two dosages." On 8/3/01, following review of lab results, the MD noted, "It is interesting to note that kD 25, 28 and 45 are separate antibodies showing that this PT had Lyme disease more than 2 yrs ago, separate from the Lymerix [sic] vax." He also indicated that babesiosis and human granulocytic ehrlichlosis developed prior to LYMErix admin. The vaccinee remained under the care of this MD until at least 4/18/02. During this time, it was noted that at times the PT felt better but that progress was slow. In a report made to the dept. of health on 3/15/01 the MD indicated that the vaccinee experienced "Arthritis characterized by brief attacks of swelling in 1 or a few joints." On 7/17/01 the MD noted that the vaccinee "had a strong Herxheimer reaction from the PCN class of antibiotic." At times he had to take mirtarapine (Rameron) at bedtime to be able to sleep. Add'l Dx's made by this MD included human herpes virus, type 6 investion (10/25/01) for which he prescribed valacyclovir hydrochloride (Valtrex). During this time period the MD also prescribed atovaquone (Hepron), atovaquone/proquanil (Malarone), and amoxcicillin/ clavulante (Augmentin). As of 4/18/02, the MD noted that he was going to discontinue all antibiotics. The most recent info, received 8/23/02, did not provide the oucomes of the events.**