Age: 18.0
Sex: F
Vaccine: HEP, MNQ, MMR, TD
Symptoms: CSF test abnormal, Hypoaesthesia, Myelitis transverse, Skin ulcer
Clinical narrative: Initial report received from the pt's father, who is a physician, on 29Aug05. An 18 yr old female pt received an injection of Decavac, lot number U1565DA, in the right deltoid on 02Aug05, ten days later, she developed numbness in her right arm, right chest and right foot. At the time of this report, she had not recovered. Follow up information was received on 13Oct05 from the pt's father and also from the responsible physician. Based upon the new information provided, it was decided to upgrade this case to serious as per medical judgement. Follow up information was also received from the consulting neurologist and is being included in this version. It was reported that the pt received a dose of MMR, lot number unk, on 02Aug05 in addition to the aforementioned Decavac. The responsible physician reported that the pt had previously received a first dose of Menactra, lot number U1657AA, administered IM in the right deltoid and a first dose of Hep B vaccine, lot AHBVB074BA, IM in the left arm on 07Jul05. 19 days after receiving Decavac and MMR (previously reported as ten days later) and 45 days after receiving Menactra and Hep B vaccine, the pt experienced numbness in her hands and arms. An MRI showed a lesion in her spinal column at level C-2 or C-3. This lesion caused symptoms of numbness in the pt's hand and arms. Five weeks later, she experienced numbness in her legs and feet. An MRI revealed a second lesion, more posterior that the first, at level C-3. The second lesion was quite distinct and was not a continuation of the first. The pt was referred to a hospital for consultation, but was not hospitalized for the events. After the second lesion was discovered, the pt was treated with IV solumedrol tapered doses over five days. Her definitive diagnosis was transverse myelitis. At the time of this report the pt had not recovered from the events. The symptoms in her hand and arms are abating and the symptoms in her feet have shown a slight improvement. It was reported that the pt had no significant past medical history or recent sick contacts prior to the onset of symptoms. The pt's father reported that the product received on 02Aug05 was Adacel rather than Decavac, but no lot number was provided. The number previously provided for Decavac, U1565DA, was verified as a valid lot number for this product. The physician's office was contacted on 14Oct04 to verify which product the pt received, but they were unable to confirm it at this time. A request for medical records was sent to the responsible physician on 13Oct05. Information was received on 18Oct05 from the consulting neurologist. He stated that the pt's outside medical records confirm the diagnosis of transverse myelitis. Her symptoms began around the last week of Aug 05, approx two weeks after diphtheria and tetanus and six weeks after the meningococcal vaccine. MRI imaging on 22Sep05 confirmed an active inflammatory lesion at C2-3, while MRI of the C-spine on 06Oct05 showed resolution of that lesion and the appearance of a new active inflammatory lesion at C3-4. MRI's of the brain on two occasions were normal. CSF examination on 09Sep05 showed only four WBC's but a markedly elevated IgG index (1.45, normal less than 0.7) and the presence of oligoclonal bands. It was determined, as based upon both the CSF and the imaging, that the pt met the criteria for transverse myelitis. As per the neurologist, it is unclear whether this is a case of isolated transverse myelitis or part of a wider disease, such as multiple sclerosis. The presence of oligoclonal bands is suggestive that she has an increased risk of this ultimately being MS, but the pt does not meet the criteria for MS at present (need two radiologic and/or clinical attacks separated by three or greater months).