Age: 15.0
Sex: M
Vaccine: MNQ
Symptoms: Abnormal behaviour, Affect lability, Alanine aminotransferase increased, Anger, Aspartate aminotransferase increased
Clinical narrative: Initial report received on 16 August 2007 from a nurse.  A 15 year-old male patient, with no concurrent illnesses, and a past medical history of acne and a questionable reaction to Amoxicillin (date not provided), had received a first intramuscular "lower" left deltoid injection of Menactra, lot number U2371AA, on 16 August 2007 at 09:15 a.m.  The patient subsequently went to the dentist to get a filling placed on his tooth; and approximately four hours post-vaccination, around 13:00 p.m., the mother called the physician to report that approximately thirty minutes prior, the patient was "acting weird and just went out of control".  Reportedly, he became weak and was angry intermittently.  It was also reported the patient had severe crying for more than three hours after the vaccination.  According to the mother the symptoms "just came out of nowhere" and the patient was quoted as saying "I'm sorry, what's wrong with me, why do I feel this way?".  Reportedly, the patient was not feverish and denied any headache.  The mother took the patient to the urgent care center for evaluation.  At 08:30 a.m. that same morning, the patient had laboratory work that revealed leukocyte count of 4.3 (range 4.5-13.0 L) and AST level of 100 (range 11-36 U/L).  It was also reported the patient had previously received a "lower" left deltoid intramuscular injection of a vaccine (type not reported), manufacturer, GlaxoSmithKline, lot number AC52B016BA, on 09 August 2007.  The reporter did not indicate whether any adverse events were experienced by the patient after that vaccination.  Treatment received and diagnostic testing performed at the urgent care center was not provided.  The patient recovered from the adverse events.  Follow-up information received on 17 September 2007 from a nurse.  A copy of the emergency room note from 16 August 2007, and the follow-up physician notes from 17 August 2007 were provided.  The patient had also received a dose of Boostrix vaccine (manufacturer GlaxoSmithKline), lot number AC52B016BA, in the left deltoid, along with a dose of hepatitis A vaccine on 09 August 2007.  The trade name, manufacturer name, lot number, route and site of administration of the hepatitis A vaccine was not provided.  The route of administration for the Boostrix vaccine was not provided.  The patient presented to the emergency room on 16 August 2007 with a complaint of emotional lability with anger episode and crying (which lasted approximately one and a half hours) after receiving the Menactra vaccine that morning.  The patient had no prior psych history or behavioral changes.  He had no fever, chills, or numbness.  Family history included diabetes mellitus.  Prior to the physical examination the patient was exhibiting no symptoms.  Physical examination was negative and the diagnosis of emotional lability was made.  The patient was sent home with aftercare instructions.  The following day (17 August 2007), the patient was seen by his physician for follow-up.  A physical examination the week prior had been normal.  The patient had routine blood work drawn on 16 August 2007, just prior to receiving the Menactra vaccination (results not reported).  The day of the follow-up visit, the patient reported having an upset stomach that morning, and the night before, was "feeling poor".  The physical examination revealed the patient with no nausea, vomiting, constipation, or diarrhea.  His energy was "fine".  A stat complete blood count was taken and "it again showed the white blood cell count at about 4000, and otherwise within normal limits".  Mononucleosis test was negative, and hepatic profile showed less elevated AST, but was still in the 60 range.  The ALT laboratory result was in the 100+ range.  A urine drug screen was negative.  Medical assessment was reported as elevated liver function test, probably viral illness, rule out infectious mononucleosis even though the mono test was negative that day.  "We doubt he had a reaction to the meningococcal vaccine, as the AST was drawn prior to the MCV4 administration."  No other treatment was provided.  A repeat mononucleosis laboratory test on 22 August 2007 was negative.