Age: 21.0
Sex: M
Vaccine: HEPAB, IPV, MEN, MMR, TD, HEPAB, YF
Symptoms: Depression, Diarrhoea, Difficulty in walking, Dysuria, Encephalitis
Clinical narrative: This healthy 22 year old male on May 11, 2004 received 8 immunizations (Polio virus, Influenza, MMR, Meningococcal, Twinrix #1, Tetanus-Diphtheria, and Bicillin).   Approximately 8 June 2004 he reports his face began to feel numb and it felt as if his arms and legs were asleep.   He received Twinrix and Yellow fever vaccinations on 09 June 2004.  After these vaccinations, he reports a throbbing headache centered to the back of his skull radiating up and over the top of his head without fever, rash or difficulty bending his neck. He placed this headache as a 5-6/10 that lasted a total of three days.  He associated this headache with previous stress headaches.  His headache persisted for the next 2-3 days and by 12 June 2004 his arms were numb, he could not bend to put his socks on, was unable to hold a pen, he began having difficulty urinating and walking.  He called 911 and was taken to the hospital.  He reports having had an upper respiratory illness the last week of May, no recent travel, no insect bites, new medications or past history of paresthesia.  His medical records document dental surgery for removal of 3 wisdom teeth on 10 June 2004 with Vicodin given.  He states he only took one or two of these for pain then stopped.   While hospitalized, he stated the numbness extended from nipple line to his toes including both arms as if "someone drew a line across my body and everything below the line was numb."  He complained of myalgia, arthralgia, difficulty in eye-hand coordination, inability to hold a pen, spasms and arm shaking bilaterally, loss of sensation chest to toes, inability to walk, inability to dress him self, and inability to void.  He stated he could tell if he was touched but not with what.  Full laboratory and diagnostic studies including an MRI of the brain and a lumbar puncture suggested a possible diagnosis of Guillain Barre Syndrome, Multiple Sclerosis, and Acute Disseminated Encephalomyelitis (ADEM).  He stated it took one month for his headaches to totally resolve and sensation to begin to return to his extremities. He spent "175 days" on medical hold in physical therapy prior to being sent home on "temporary retirement" on 25 November 2004 to await further orders.  (Seem MEB and medical records write-up below).    The MRI of the brain on 12 June 2004 showed several nonspecific abnormal regions of high T2 signal within the periventricular white mater along the high convexity at the parietal level and frontoparietal confluence as well as poorly defined abnormal high signal within the pons.  A repeat MRI done on 4 November 2004 failed to re-demonstrate these lesions or additional sites of abnormal signal within the brainstem or white matter.  Overall, the lack of re-demonstration of these lesions speaks against an ischemic etiology.  These lesions were most likely present on the basis of an additional and probable autoimmune etiology as can be seen in ADEM more so than demyelinating lesions of multiple sclerosis.  As of this interview, 7 December 2004, he can use both arms with increasing strength with periodic weakness every 3-4 days, yet still "not like before".  He has progressed from wearing knee braces and use of a walker-cane to "walking on his own".  He experienced swelling to his right knee and ankle late June 2004 with his physical exam reporting a positive Holman's sign.  Radiographic x-rays were normal.  His ultrasound was negative for deep vein thrombosis. He denies reoccurring swelling however he continues to have daily bilateral knee and hip pain with radiating pain up his back into his neck.  His reports his legs give out periodically and "do not work right".  Neurology follow-up evaluation on 29 October 2004 documented his "ADEM was most likely secondary to vaccinations.  His MRI of the brain MRI showed normal intracranially with opacification in the R frontal and ethmoid sinuses.  The doctor's impression was that the SAA had resolved.  There is no evidence for any active neurological disease at this juncture.  Although he still has urinary difficulties, neurological eval for this has been normal  although this could be a residual (theoretically) of his ADEM, it would be unusual as the rest of his difficulties as well as his neuro exam and tests have completely cleared.  He needs to see his PCM for further eval of sinus disease".   He continues to have difficulty with urination feeling "urges to void all day", a foul odor, dribbling and burning through out his stream.  He has periodic episodes of urinary incontinence 2-4 times a week at night requiring the use of adult diapers.  He is catheterizing himself 2-4 times per day.  He is able to urinate spontaneously approximately 50 cc of urine with post-void residuals ranging from 800?250 cc of urine.  A Cystoscopy performed on June 2004 documented no anatomic abnormalities.  It was felt that the patient's bladder dysfunction was neurogenic, probably secondary to his primary neurologic diagnosis.  His urge incontinence was associated with "re-awakening" of the bladder.  Detrol 2-4 mg PO daily and Urospasm were added with good results.  He also is concerned about bowel incontinence with complaints of constipation and abdominal pain.  He reports his bowel movements have gone from twice a day before June 2004 to a bowel movement every 5 days. He describes hard formed brown stool with periodic episodes of watery incontinence.  These episodes occur with sudden abdominal pain and the urge for a BM resulting in leakage incontinence if unable to access a bathroom. He reports one monthly episode of bloody flecks on his stool.  All other stools are normal.  He denies fissures, hemorrhoids or trauma to the rectum.  He is currently on Surfak and Lactulose.  He also continues to have excessive fatigue, short-term memory loss and diffuse joint pain.  He states he is unable to exercise due to his fatigue; he wakes up tired after sleeping 20 hours.  He currently sleeps about 10 hours a night and naps twice a day for 4-5 hours.  His mother reports he twitches and jerks his extremities while sleeping.  He states he needs to write notes to himself as his short term memory has been impaired since June 2004.   He was diagnosed with depression upon release home in November 2004 and placed on Lexopo with minimal results.  He is arranging follow-up at a hospital for continuation of care.