Age: 31.0
Sex: M
Vaccine: FLUN3
Symptoms: Electroencephalogram normal, Electromyogram normal, Electrophoresis protein, Epstein-Barr virus antibody positive, Fall
Clinical narrative: The pt received FLUMIST on 8/31/09; the pt was in his normal state of good health. Around 10/9/09 the pt experienced a sore throat, headache, and he felt feverish. On 10/11/09 he noted a burning pain (8/10) on the top of his right foot which progressed to his left forearm then his right forearm and then to his quadriceps. The pt states that when he got out of bed on 10/12 he fell. He states that his face was numb; he was drooling, his speech was slurred; he had severe back pain and he was unable to move his fingers. The pt was transported by ambulance to ER. A CT of the head was negative and the pt was released. While walking to his car he experienced severe pain in his scrotum, upper thighs and arms. His wife took him to ER where he also complained of a headache and a sore throat. The pt was admitted. He was diagnosed with possible GBS. The pt received a 5 day course of IVIG with improvement of his symptoms. The pt was evaluated by Infectious Disease, Rheumatology, Neurology and Physical Therapy. His workup including MRI of cervical spine/brain, MRA, viral studies and spinal tap was basically normal. The pt was transferred to acute rehab on 10/22/09 with symptoms of arthralgia, myalgias, paresthesias, complaints of blurred vision, double vision and difficulty focusing. On 10/24/09 the pt was noted to have two episodes of "eye rolling", unresponsiveness and lower extremity twitching. The pt was transferred back to hospital. "Pt is aware during event, not postictal and not typical tonic-clonic seizure. CT, EEG, labs were basically normal. On 10/29/09 the pt was transferred back to rehab. Neurology consult on 10/30/09. On 11/5/09 the pt complained of worsening weakness in lower legs, burning pain in his thighs and unilateral headache (right side) with some numbness to the right side of his face. 11/6/09-11/10/09 pt was transferred to acute care and given 4 doses of IVIG. Repeat EEG, MRI (cervical/thoracic spine) wnl. EMG/NCS (not suggestive of a central or peripheral neuropathy) see results below. 11/16/09 Ophthalmology consult: "No evidence of MF variant". The pt began to complain of urinary retention which was originally thought to be a side effect of pain medication. This improved for a period of time but has not abated. The pt was discharged from rehab on 11/18/09. 11/23/09 Neurology consult: PE "visual acuity and visual fields are intact; EOM intact, no nystagmus. On downgaze: pt looks down with his eyes globes moving symmetrically, then quickly moves his eyeballs up-started blinking. UE: 5/5 inconsistent effort; LE 5/5 inconsistent effort. Sensory: equal to light touch, position and pin prick, vibration sensation is diminished bilaterally. DTRs: 2+ and symmetric. Toes down going bilaterally. Assessment: generalized weakness, mostly subjective. Poor compliance with exam, likely some functional overlay". After review of extensive testing the diagnosis of GBS was dismissed by the patient's civilian neurologists. The pt   [Due to memory limitations, the remainder of this text could not be compared.]  The pt has had multiple hospital admissions for Pseudoseizures. The pt was evaluated by Mental Health and diagnosed with Dissociative Disorder for which he was admitted. He has also been diagnosed with depression and PTSD. Additional CT, MRI, EEG, LP done Jan-Aug 2010 continued to be basically normal.