Age: 21.0
Sex: M
Vaccine: HEPA
Symptoms: Coordination abnormal, Dermatitis contact, Dysuria, Gait disturbance, Grip strength decreased
Clinical narrative: The patient is a 21 year old male who was referred to clinic for assessment and case management for vaccine causality for Transverse Myelitis. He received hepatitis A #1 on 5 Jun 2015 mfx SmithKline lot #7K5T4 and on 18 Jun he received HPV #1 mfx Merck lot #L001442. We also received report he received MMR, varicella and hep B, but per review, these were data entry on 2 Jun 2015 of 'not susceptible'. He reports he felt well until approximately 1 month ago when he experienced difficulty urinating. He was evaluated, treated with and treated. He awoke one morning with tingling in his legs as if he had slept in a wrong position. Later in the day it developed in his abdomen, pelvis and legs. He was seen in ER but no abnormalities were found and he was instructed to f/u with PCM. After 2-3 days it spread to his hands and later thumbs. He had no loss of sensation. His gait was affected and states he thought it was due his coordination being affected. He was eventually referred to neurology who diagnosed him with the transverse myelitis. He was treated with steroid therapy for three sessions. His symptoms has mostly abated with only his hands not being at baseline. He states they remained tingly, numb and has difficulty with coordination and grasping. The current POC is an MRI scheduled 29 July. He is not receiving PT, has no follow up scheduled with neuro and has no further steroid therapy scheduled. We discussed his provider visit June 2 when he received hep A vaccine. He states he had nausea, severe headache, dizziness and photophobia. He does not recall any systemic malaise, fever, chills. He denies emesis or diarrhea. He was diagnosed with a migraine. He has no history of migraines. As far as the vaccine receipt, he had immediate reaction and denies urticarial lesions, dyspnea, oral, facial or throat swelling. He denies any local reaction to either vaccine of redness, edema pruritus or site pain. He noted no systemic reactions of fever, chills, malaise, arthralgias or myalgias. He has no history of adverse reaction to vaccines. Medication list reviewed with patient, reconciliation completed. Allergies: Allergies Verified and Updated. He reports a history of a local reaction to topical hemorrhoid cream causing local exanthem which resolved spontaneously. He also develops a contact dermatitis to Axe brand deodorant. No history of adverse reactions to hymenoptera stings. No history consistent with food intolerance. No history consistent with latex intolerance. Current medication: Including OTC meds, vitamins, herbals, etc. none. Past medical/surgical history Reported: Medical: Reported medical history stress fracture, hemorrhoids, constipation. Surgical / Procedural: Surgical / procedural history none. Personal history Social history reviewed does not smoke, social alcohol use approximately 2 drinks per week. Family history Family medical history Mother age 44 thyroid disease, father age 47 healthy, brother age 24 healthy, half brother age 8 healthy. Review of systems: GENERAL: no fever, chills, malaise, night sweats or unexplained weight loss HEENT: +migraine headache, + photophobia episode June 2 2015; no ear, or throat pain, no nasal blockage or discharge HEART: no chest pain RESP: no shortness of breath or cough GI: no nausea, emesis, abdominal pain, constipation or diarrhea GU: no urgency, +dysuria, no back pain. The patient is a 21 yo male with acute transverse myelitis per neurology evaluation which urological symptoms developed with temporal association to vaccine receipt of hep A #1 and neurological symptoms after receipt of HPV #1. He received 3 doses of IV steroids and most symptoms have resolved except tingling and grasp with symmetric deficits to his hands. He has another MRI scheduled this week for follow up. Per chart review he received hepatitis A on date of migraine onset, for which he has no history. He developed urologic symptoms 8 days later. He received HPV #1 16 days after hep A, and developed neurologic symptoms 6 days after the HVP and 22 days after the hep A vaccine. The patient's clinical history is less consistent with vaccine receipt as an etiology from the HPV as it is unlikely an antibody could form in this time period. HEP A vaccine is within the potential time frame, however other etiologies have to be considered. P: We will open a VAERS case, and will continue to follow, he is improved and pending MRI. Continue recommendations no further vaccine receipt for now. I provided education on what is known about vaccine receipt and transverse myelitis, and overall rareness of the syndrome. Consider PT and/or OT for his hands. I provided education on our services, purpose and all questions were answered and contact numbers provided for any further questions.