Age: 38.0
Sex: F
Vaccine: MMR
Symptoms: Parkinsonian gait, Parkinsonism, Resting tremor, Restlessness, Rubella antibody negative
Clinical narrative: Information has been received from a health care professional, author of a literature article, concerning a 38-year-old woman who underwent a general health examination in 1987, in preparation for starting a job as a nurse. Because she had negative serum rubella titers, she received an MMR II (dose, route and lot number not reported). Soon after the vaccination, she developed nausea and left-sided slowness, weakness, and upper extremity tremor. Over the following months, she was evaluated by several neurologists who also noted rigidity and bradykinesia involving her left side. Brain magnetic resonance imaging (MRI) at the time and at present revealed scattered periventricular and deep T2/FLAIR hyperintensities in the bilateral thalami, internal capsule, and left cerebellar hemisphere, none of which enhance with gadolinium. These hyperintensities had neither enhanced nor changed in configuration on serial MRIs over 20 years, and were believed to be consistent with post-vaccination encephalomyelitis. In the year following her vaccination, her left upper extremity rest tremor worsened and she developed a parkinsonian gait. She was initially treated with amantadine, which helped her rest tremor. Soon afterwards, carbidopa/levodopa (manufacturer unknown) were added which further improved her tremor. Approximately five to seven years after starting carbidopa/levodopa (manufacturer unknown), she experienced wearing-off symptoms with prominent left-sided rigidity (WAES#1202USA03822) for which pramipexole was effective. She expressed interest in Deep brain stimulation (DBS) in 2005, but was not offered surgery due to her diagnosis of secondary parkinsonism. Her best "on" times tended to come in the mornings. During these times she felt loose and could walk with minimal assistance. This allowed her to work in the garden independently, an important aspect of her quality of life. During her "off" times she was completely dependent on her husband for all activities. She never had dyskinesias, hallucinations, depression, or cognitive complaints. Neuropsychological evaluation showed no dementia. Her MDS-UPDRS motor score was 79 off medications and 54 on medications, representing a 32% improvement with dopaminergic therapy. Her medications included carbidopa/levodopa (manufacturer unknown) 25/100, 2 pills given 5 times daily, pramipexole 1.5 mg four times daily, amantadine 100 mg three times daily, entacapone 200 mg three times daily, and oxybutynin 5 mg three times daily. The patient underwent bilateral STN DBS electrode placement followed a month later by implantation of a Kinetra stimulator and had no tremor or wearing-off symptoms once stimulation parameters were optimized. At six month follow-up, MDS-UPDRS motor scores were 63 off-medication/on-stimulation and 44 on-medication/on-stimulation. At one year follow-up, her MDS-UPDRS scores remained stable at 53 off-medication/on-stimulation and 45 on-medication/on-stimulation. LED was reduced by 57% at one year follow up. Additional information has been requested.