Age: 38.0
Sex: M
Vaccine: LYME
Symptoms: Activities of daily living impaired, Amnesia, Arthralgia, Autoimmune disorder, Borrelia burgdorferi serology negative
Clinical narrative: This case was reported by a lawyer and described the occurrence of joint pain in a male subject of unspecified age who was vaccinated with LYMERIX (GlaxoSmithKline). A physician or other health care professional has not verified this report. The subject's medical history, concurrent conditions and concurrent medications were not reported. On an unspecified date the subject received unspecified dose of LYMERIX (unknown). An unknown amount of time after vaccination with LYMERIX, the subject experienced joint pain, flu-like symptoms, autoimmune disease, activities of daily living impaired, muscle pain, memory loss, headache, rheumatological symptoms, neurological impairment and cognitive impairment. At the time of reporting the outcome of the events was unspecified. This information was received via a Statement of Injuries. Follow-up was received on 26 August 2008 via medical records. On 13 September 2002, the subject was evaluated and reported to have tendonitis and bursitis of the shoulders. There was also some peaking in the knees and some mild degenerative joint disease of the shoulders. It was documented that the physician was unsure how much of the pain was due to degenerative changes, his HLA-B27 propensity to AS and how much was due to the Lyme vaccination. Records dated 01 September 2004 indicated that the subject experienced a left ureteral calculus for which he had a ureteral stent placed in the early part of August 2004. The subject had undergone extracorporal shock was lithotripsy on 18 August 2004 with successful break up of the stone. The stent was later removed. There was no indication that this event was connected to the subjects claimed events and Lyme vaccine, the subjects condition was simply documented in medical records. The same record mentioned that the subject had been experiencing arthralgias presumably secondary to Lyme vaccine. Follow up information was received on 03 November 2008 via medical records. In April 2000 and May 2000, the subject was evaluated for left and right shoulder acromioclavicular joint pathology and impingement, treated with unspecified anti-inflammatories. On 07 June 2000, the subject was evaluated for bilateral acromioclavicular joint arthritis. On 10 April 2002, the subject was seen for multiple complaints including bilateral shoulder and knee pain and right hip pain. Examination resulted in an impression of bilateral impingement acromioclavicular arthritis, bilateral knee pain syndrome, and mild greater trochanteric bursitis of the right hip. On 23 April 2002, diagnostic findings included subacromial/subdeltoid bursitis, possible mild impingement syndrome, mild osteoarthritis of acromioclavicular joint, and minimal rotator cuff tendinopathy. In May 2002, magnetic resonance imaging of the left shoulder showed acromioclavicular joint derangement, with similar findings of the right shoulder to a lesser degree. On 27 June 2002, the subject underwent a surgical procedure for left shoulder impingement with acromioclavicular arthrosis and slap lesions and partial thickness rotator cuff tear. A note from the subject's insurer indicated that he required a hospital stay for an unspecified reason prior to 01 August 2002. In June 2002, medications included OXYCONTIN. The subject was seen by an arthritis/interal medicine specialist on 13 September 2002 due to complaints of left shoulder pain which reportedly developed three weeks after his first LYMERIX vaccine in June 1999. He subsequently experienced knee pain and hip "twinge", and at the time of examination on 13 September 2002 the knee pain was continuous with a numb effect. Other complaints included right sciatica, joint tenderness, and shoulder tendonitis and bursitis, and he was noted to be HLA-B27 positive. Treatment included MOBIC. On 05 November 2003, he presented for residual distal clavicular pain of unclear etiology, one and a half years post-operative acromioclavicular (AC) joint resection. On 20 December 2003, magnetic resonance imaging of the left shoulder showed no evidence of rotator cuff tear, with some changes at the AC joint consistent with interval decompression surgery. In February 2004 he complained of episodic paresthesias in the distal legs status post Lyme vaccine with multiple joint pain. Electrodiagnostic test results were "compatible with a normal study". On 10 March 2004, the subject underwent decompression of the left ulnar nerve, followed by numbness in the right small finger. It was noted that it was "within reasonable medical probability that the injury to the right ulnar nerve at the elbow was the direct result of a motor vehicle accident on 13 November 2003". ON 21 January 2004, the subject's left shoulder was re-evaluated by his orthopedist with a resultant impression of "recurrent pain and numbness after an acromioclavicular joint resection". On 17 February 2004, symptoms included left ulnar nerve neuropathy. Upon follow up on 09 September 2004 he complained of some intermittent paresthesias. On 27 October 2005 he complained of some sensation and paresthesia around the small and ring finger as well as around the surgical incision site. He also received physical therapy for a diagnosis of right elbow cubital tunnel syndrome from 02 November 2005 to 30 November 2005. On 24 April 2001 the subject was seen after injuring both tibias after falling, and was diagnosed with left and right tibial contusions. In approximately October 2002, the subject twisted his right knee and was diagnosed with a right knee medial collateral ligament injury. On 13 November 2003, the subject was involved in a motor vehicle accident resulting in thoracic strain and sprain, treated with physical therapy, VOLTAREN, and FLEXERIL. In November 2003, the subject experienced a right ringer mallet injury. In March 2008, the subject injured his right knee and impression included bony contusion of knee. Treatment included VOLTAREN and a knee brace. These events were assessed to be incidental findings upon review of medical records.