Age: 66.0
Sex: F
Vaccine: FLU3, PPV
Symptoms: Myoclonus, Nervous system disorder, Nuclear magnetic resonance imaging normal, Ophthalmoplegia, Pain
Clinical narrative: This literature report (initial receipt: 04-Nov-2011) concerns a 66-year old female patient. The patient received flu shot as well as PNEUMOVAX. On 21-Oct-2007, a week or so after vaccination, the patient presented to hospital with complaints of progressively worsening neurological. The patient stated that she had onset of headaches a week or so before admission, soon associated with some numbness and tingling in her hands and feet, and later associated with dysarthria and swallowing difficulties, prompting her to get further medical attention in the emergency room. The patient had no viral-type illnesses. The patient was evaluated by neurology with multiple tests, MRI and MRA scans demonstrated no significant abnormality that could have caused her symptoms. With the patient's history, physical, and diagnostic testing done, she was diagnosed with Miller-Fisher variant of Guillain-Barre syndrome. The patient was treated with intravenous immunoglobulin. At this point, the patient noted stability in her course, no worsening, but had not noted much improvement either. Overall, she felt somewhat weaker on the left versus the right, but noted significant difficulties with coordinating her movements. She also noted residual numbness and tingling involving her face, the inside of her mouth, in her lower extremities in a knee sock-type distribution and in a glove distribution in the upper limbs. She did admit to facial weakness with some dysarthria; however, noted improvement in her face and in her speaking. She was experiencing some intermittent bouts of pain. She had pain in her limbs, particularly her legs, described as a combination of burning pain, cramping, and irritating numbness and tingling. The patient was on gabapentin. The patient also developed what she called "spells", where she experienced an autonomic instability giving her a 3- to 10-minute period of dizziness, change in vision, headache, and hypotension. The patient was previously fully independent with activities of daily living as well as ambulation. She had no medical limitations. On physical examination, the patient had difficulty in her feet with digit identification as well with proprioception, which was absent at her toes. Light touch sensation was decreased beginning at about the mid thigh level and gradually worsening down to her toes. Upper extremity sensation was not as markedly decreased as in her feet, but there was decreased light touch sensation in bilateral hands as well as decreased vibratory sensation. Myoclonus was present bilaterally in both lower extremities. Rotational dystonia was also present in her ankles, more pronounced on her left side. Digit identification was intact in her hands. With manual muscle testing in general she had 4/5 strength in her limbs, with hand intrinsics being weaker, but she was able to give some minimal resistance with intrinsic testing. Reflexes were obtained at her ankles, 1+ at the knees, and 1+ in her upper extremities. Extraocular movements were intact. No nystagmus was noted. Mild facial weakness was noted bilaterally. Her speech was mildly dysarthric. There was significant ataxia with attempts at gross as well as fine motor movements, more pronounced in the lower extremities versus the upper extremities. The patient had findings of rapidly progressive ascending limb weakness, accompanied by paresthesias, pain, and cranial nerve dysfunction. The patient also had acute symptoms of ataxia, ophthalmoplegia and decreased reflexes. The event outcome was not reported. Reporter's comments: The patient's risk factor that is believed to have led to her disease was the influenza and/or PNEUMOVAX vaccination a week prior to the symptoms. Recent influenza immunization has been associated with GBS. The Vaccine Adverse Event Reporting System, which is administered by the Centers for Disease Control and Prevention and the US Food and Drug Administration to monitor reports of suspected adverse events after immunization, concluded in its 2003 surveillance summary that the risk of developing vaccine-associated Guillain-Barre syndrome is less than the risk of severe influenza. In addition, despite increasing doses of administered vaccine during  the 4 previous influenza seasons, the number of Guillain-Barre syndrome reports has remained stable.