Age: 18.0
Sex: M
Vaccine: FLUN3, IPV, TDAP, YF, FLUN3, HEPAB, IPV, TDAP, YF, FLUN3, HEPAB, IPV, TDAP, YF, FLUN3, HEPAB, IPV, TDAP, YF
Symptoms: Hypotonia, Immunology test, Lumbar puncture normal, Muscular weakness, Pain in extremity
Clinical narrative: Initial report received on 07 March 2008 from centers.  A search of the CDC VAERS database was completed on 13 March 2008 which also revealed additional information for this case.  This case involves an 18-year-old male, whose past medical history included a cough, and exposure to other recruits with diarrhea, but no history of diarrhea since arrival on 02 August 2006.  The patient has an allergy to Penicillin, but had no other illness, or past medical issues (specifically hypertension, thyroid disorder, diabetes, or epilepsy).  He also had no caffeine, tobacco, or alcohol use.  On 02 August 2006, the patient received a dose of MENOMUNE (lot #, route and site of administration not provided); a dose of MMR (trade name, manufacturer name, route and site of administration not provided); a dose of PNEUMOVAX (trade name, manufacturer name, route and site of administration not provided); and a first dose of TWINRIX (manufacturer GSK, route and site of administration not provided).  On 29 August 2006 the patient subsequently received a first, subcutaneous, left arm dose of YF-VAX (lot # VEG01AA); a first, subcutaneous, right arm dose of IPOL (lot # V1051); a first, intramuscular, right arm dose of ADACEL (lot # C2457AA); a first, intranasal dose of FLUMIST (lot # 500430P, manufacturer Medimmune, Inc./Wyeth laboratories, Inc.); and a second, intramuscular, left arm dose of TWINRIX (lot # AHABB061AA, manufacturer GlaxoSmithKline).  On 30 August 2006, the patient developed progressive ascending weakness in his hands and feet bilateral, with gait disturbance, numbness, "pins and needles", intermittent tingling of feet, and calf pains.  He had no fever, rash, headache, stiff neck, diplopia, trouble breathing or swallowing, dysuria, or incontinence.  Physical examination revealed an awake, alert and oriented patient.  Examination of the neck was normal, and neurological examination revealed normal cranial nerves II-XII, no sensory abnormalities, normal muscle tone and bulk, and normal strength of face and neck/cervical spine.  The patient had decreased strength of the upper (4/5) and lower (3/5) extremities (grip strength decreased).  He had asthenia, was unable to walk unassisted, abnormal biceps and brachioradialis (1+) reflexes, absent or diminished ankle jerk, and knee jerk was normal.  The patient's toes were flaccid with Babinski testing.  The patient was subsequently admitted to the intensive care unit in the hospital on 02 September 2006, and his respiratory status was monitored with frequent pulmonary function tests.  He did not require intubation or other respiratory support.  Treatment included Heparin (deep vein thrombosis prophylaxis), and IVIG 42 gm daily for three days.  Diagnostic laboratory studies revealed a lumbar puncture test that was "negative for albuminocytologic dissociation" but cultures and PCR were still pending at the time of this report.  An "EMG" revealed "electrophysiologic evidence of a severe motor greater than sensory, acquired multifocal sensorimotor peripharal neuropathy with axonal, greater than demyelinating features.  Per the reporter, given the history of the patient, this likely represented a variant of Guillain-Barr syndrome.  Frequent pulmonary function tests.  Result not provided.  Yellow fever studies revealed evidence of recent vaccination with yellow fever vaccine.  No yellow fever viral RNA was detected, and IgM Capture ELISA was negative for all serum samples.  PRNT (+Control >2560) was <10 for serum sample #1, 10 for serum sample #2, 10 for serum sample #3, 20 for serum sample #4, 20 for serum sample #5, 10 for serum sample #6.  The patient was discharged after five days of hospitalization.  Recovery status at the time of this report was unknown.  Guillain Barre Syndrome is an acute inflammatory polyradiculoneuropathy caused by an immune reaction to a preceding event, often an acute infectious illness.  In this case, the young patient might have a exposure to gastrointestinal infection as he had a contact with other recruits with diarrhea.  Yellow fever studies were not in favor of a role of the vaccine in the onset of the event.  Thus, alternative etiology, and in particular Campylobacter jejuni infection, should be searched in this case.