Age: 18.0
Sex: F
Vaccine: HPV4
Symptoms: Nerve conduction studies normal, Neuritis, Neurological examination normal, Nuclear magnetic resonance imaging normal, Pain
Clinical narrative: I have been experiencing bilateral muscle fatigue and pain in feet and legs for almost three years now. They began when I was a 19 year old female pre-medical college student with a history of moderate alcohol use and smoking, and no major diseases except mild scoliosis as an adolescent and shingles at age 17, which indicates some auto-immune issues. I wear orthotics for my flat feet and have a history of swollen Achilles tendons and other feet problems. I was in great physical shape as I exercised five times a week for an hour. After volunteering in a hospital, on my feet for three hours, I experienced a sudden onset of intense foot pain in February 2007 which disabled my mobility for the rest of the day. From then on, my leg muscles were extremely weak and fatigued so much that I was not able to climb up stairs or walk from my dorm to classes on campus. I also experience sporadic pain throughout different places in my legs and feet, including knee, ankle, thigh, and foot pain. Sometimes the pain is so bad I will all of a sudden be forced to limp as I cannot put any pressure on my foot after it has a sort of spasm. I sometimes experience these spasms while driving and have to pull over and can no longer drive, and I can no longer drive longer distances. I also experience stiffness and aches in my legs and feet late in the night, in the mornings, and after keeping them in one position for awhile. After I drink alcohol, my symptoms become worse and more frequent for the following week proportionate to the amount of alcohol consumed.  Podiatrist Evaluation Feb. 2007: Podiatrist examined my orthotics which were too old and diagnosed me with congenial pes planus and limb pain. Podiatrist took a slipper cast of each foot and made orthotics which corrected the pes planus as best as they could. Podiatrist ordered physical therapy three times a week to strengthen my leg muscles which were extremely weak during strength and resistance testing. Podiatrist referred to a back specialist to determine if any lower back problems at the Center are influencing her current issues.  Spine Specialist Evaluation March 2007: Orthopedist took an X-Ray of lower back which was normal. Orthopedist ordered a nerve conduction test and electromyography (EMG) at the electrophysiology department of the Center. Sports Medicine Evaluation March 2007: Physician ordered a complete metabolic panel clarification, Lyme disease, rheumatoid factor, and other auto-immune work ups. All of these blood tests came back negative. Physician noticed an enlarged thyroid gland and referred to an internist for an ultrasound of her thyroid. Internist Evaluation: At the Clinic, upon examination the thyroid appeared normal which blood tests later confirmed. The physician felt there was no need for an ultrasound. I was referred to a neurologist.  Neurologist Evaluation May 2007: Neurological examination was normal. Neurologist ordered more blood tests and a head MRI as he suspected parvovirus was the cause of the sudden, intense symptoms. The MRI was normal, ruling out MS as a possibility as there was no evidence of CNS white matter lesions. I demonstrated positive levels of parvovirus B19, HSV 1 herpes select, and Epstein Barr VCA. The Neurologist felt his diagnosis of parvovirus was appropriate and assured her symptoms would completely disappear within 6 months of onset. Parvovirus can affect adults with immune issues and manifest itself with bilateral joint pain and swelling. The adverse reaction to alcohol and muscle weakness and fatigue are not typical of parvovirus infections.   Rheumatologist Evaluation June 2007: Ordered more blood tests and ruled out the diagnosis of Rheumatoid Arthritis with his physical examination and supported the diagnosis of parvovirus. Epidemiologist Evaluation July 2007: Ordered more blood tests with inconclusive results.  Primary Care Physician June 2007: I visited my regular doctor multiple times throughout this experience who considered a diagnosis of fibromyalgia. The G.P. attempted to treat the excess inflammation in my legs with Mobic and Naproxen. I was allergic to Mobic and developed harsh acid reflux problems from the Naproxen. She later prescribed more mild medications including Folbalin Plus (Vitamin B12) and Flax Seed Meal. Through many blood tests, I had elevated levels of cholesterol, triglycerides, LDL cholesterol, and HDL cholesterol but no other positive results linked to my problems. Homeopathic Physician August 2007: After I was completely frustrated with the mixed diagnoses from the many doctors and no possible options for treatment besides "waiting for the symptoms to go away", I sought out an alternative practitioner. He concluded these problems are the result of an adverse reaction to the Gardasil vaccine, manufactured by Merck, which I have received three times; in August 2006, November 2006, and May 2007. He focused on building up my immune system with homeopathic remedies, as my history of shingles demonstrates I have a weaker immune system.   Follow up with Podiatrist September 2007: Wearing the orthotics has corrected the majority of gait problems I was experiencing. I described my fatigue problems while swimming, which troubled the Podiatrist as he knows this is no longer a foot problem. I was able to swim at a moderate pace, however when I get out of the water, my leg muscles were extremely fatigued and achy for the rest of the day. He thought my nerves had to fire more frequently to produce movement, which caused the fatigue, yet was not a prominent enough problem to show up on the EMG. The Podiatrist urged me to completely quit drinking alcohol, continue physical therapy, and build up my immune system. The final diagnosis made by the Podiatrist included neuropathy and unspecific neuritis along with the previous diagnoses. Vascular Surgeon Evaluation January 2008: Referred to a vascular surgeon in order to investigate any vascular issues in my legs. I first received an echocardiogram at the Clinic with no serious results: only mild tricuspid and mitral valve regurgitation with normal left/right ventricular systolic function and pulmonary artery systolic pressure. Upon examination, I did not have a pulse in my feet while they were working against resistance. In an attempt to investigate the possibility of popliteal artery entrapment syndrome, the surgeon performed a bilateral angiogram on my legs and feet. With negative test results, the surgeon told me he can no longer help me. Follow ups with Homeopathic Physician October 2007 - Present: I quit drinking alcohol in August 2007 and continued to participate in physical therapy and to take homeopathic supplements which strengthen my immune system without other negative side effects. The pain progressively became less frequent and less intense, while other problems worsened especially stiffness and fatigue. I was sleeping 15 hours a day, and felt extremely lethargic and tired while awake. I started acupuncture treatments twice a week, in June 2008, to help with this new problem. By January 2009, I was able to walk up the stairs without fatiguing, drive shorter distances, walk around for a few hours on my feet without pain, and participate in mild exercise including yoga, skiing, and weightlifting. I appears to be on a gradual road to a full recovery. However, with the ambiguity of the cause and pathology of my condition I remain unsure but hopeful for a complete recovery. I am more focused on treating my symptoms instead of tirelessly investigating the cause.  I have experienced many of the side effects from Gardasil which call for an immediate physician appointment including: joint pain, unusual tiredness or weakness, generally feeling unwell, leg pain, aching muscles, and muscle weakness. As of now, I still have some intermittent pain in legs and feet, full body fatigue, leg muscle weakness and fatigue, stiffness in leg joints, and extreme exhaustion after working a part time o