Age: 31.0
Sex: M
Vaccine: SMALL, YF, SMALL, YF
Symptoms: Comminuted fracture, Computerised tomogram head, Consciousness fluctuating, Convulsion, Diffuse axonal injury
Clinical narrative: This case was received on 01 March 2010 via a QScan search on the VAERS database, under the reference number 369593. A 31 year-old male patient received the following vaccines on 17 June 2009: a percutaneous injection of ACAM2000 (lot number VV04-003) and YF-VAX (lot number UF434AA). The sites of administration were not reported. It was reported that the patient was well on the day of and prior to vaccination. He developed new onset daily headaches 1-2 days later, rated 5 out of 10 on a pain scale and self-treated with TYLENOL as needed. The patient reported no visual disturbance or any other neurologic, systemic or constitutional symptoms, except a single isolated brief episode of mental lapse described as "forgetting to make planned left turn" at a usual familiar intersection. The patient had normal take at his smallpox vaccination site. It was also reported that the patient received a first dose of Anthrax vaccine and MGC vaccine on 11 June 2009 (6 days prior to smallpox vaccination). The patient had no known allergies to drugs, foods, latex or insects. On the night of 23 June 2009, the patient had motorcycle accident (helmeted) while driving on a familiar route with good visibility and no other vehicle or pedestrian involvement; he sustained a serious closed head injury and was hospitalized for 8 days, requiring short term intubation and treatment with IV ATIVAN and KEPPRA. He was noted to have waxing/waning consciousness and seizure activity on arrival to the Emergency Department. Toxicology screen was negative. A head CT on 24 June 2009 revealed small left occipital condyle fracture with subarachnoid hemorrhage and small falx subdural hematoma; also had right clavicular comminuted fracture. Brain MRI on 26 June 2009 revealed grade II diffuse axonal injury involving splenium of corpus callosum and white lobar matter; FLAIR sequences demonstrated residual blood byproducts in falx; electroencephalogram on 28 June 2009 was normal. He was discharged on 01 July 2009 in stable condition with GCS 15, ambulating well and tolerating a regular diet. His pain was controlled with oral pain medications. He was transferred to rehabilitation facility for about 2 weeks of therapy. On 16 July 2009 the patient had an ORIF repair of his right clavicle fracture. He had vertigo post hospitalization, resolved with Epley maneuver; residual mild recurrent headaches, continued neck and right shoulder pain, and insomnia. In August 2009 N/P evaluation (per patient) indicated some deficits in processing speed, short term memory loss, and executive decision-making. He has had gradual continuous improvement but continues follow-up with speech and occupational therapy as well as neurology. He remains on a physical profile as of November 2009. Note: There may be a discrepancy between the event onset date filed and the onset date information in the free text narrative field in the data reported. Latency has been calculated using the date that is in the narrative. List of documents held by sender: None.