Age: 14.0
Sex: F
Vaccine: HPV4, MNQ
Symptoms: Lumbar puncture, Lymphadenopathy, Mononucleosis heterophile test positive, Muscular weakness, Myalgia
Clinical narrative: Pt, a strong, athletic fourteen year old volleyball player received the GARDASIL vaccine at her pedatirician's office on July 10, 2007. At that time she weighed approx 131 lbs. and had no other medical conditions other than a previously diagnosed thyroiditis (Hashimoto's) treated with SYNTHROID 75 mcg. On the day of her visit to the pediatrician for a school and sports physical she received the GARDASIL along with the Hepatitis A vaccine because we were planning on traveling outside the country later in the year. She began her volleyball training a few weeks later and although she was keeping pace she often complained of exhaustion. Because the training was vigorous, no one thought of it. School began in late August and she continued a vigorous regiment. By mid September she was complaining of back muscle pain which we thought was simply from playing. She had also begun complaining of stomach pains. By the first of October there was a marked difference in her stamina and the pain and obvious muscle weakness became more obvious. As a player who could easily seven ten to fifteen hard serves in a row during a game, she could barely put two or three serves over the net. In mid October she was seen by her pediatrician who could find nothing medically wrong with her. But by the end of October, she could barely carry her book bag in school and could barely walk the hallways during a full day of school. She was seen by her endocrinologist during the first week of November for her regular check up and this exhaustion was brought up. Lab work done revealed that if there was something wrong, it was not due to her thyroid which was functioning normally. Two weeks later she was seen again by her pediatrician, again nothing was diagnosed. Another week later she was seen again and lab work was done to rule out Strep and mononucleosis. Seven days later we were told her mono titer was positive so everyone assumed that was the cause for her fatigue. After days of bed rest, no real improvement was noted. Three weeks later, she was slightly better, but since she was out of school it was hard to gauge. Now out of school for the holidays, we left the country (with medical approval). While away, she developed enlareged nodules under the armpits and in the chest area. She also complained of face pain. Upon returning, she was seen again by the pediatrician and x-rays were ordered (chest and sinus). X-rays revealed nothing. The following week the fatigue worsen and she was seen again in the pediatrician's office and referred to an infectious disease physician to ensure that she had not contracted anything during this trip. This specialist ordered an ultrasound of the back area that was painful since Sept/Oct. and a lot of lab work including an EBV. All tests revealed there was no infectious disease (not mono); however, the ANA was positive. The doctor suggested a follow up with a rheumatologist. The rheumatologist saw her on the following week and ordered another battery of tests. By the following week, the end of January, she was extremely weak; she could not stand on her own- she could not walk on her own. She also had difficulty breathing and had chest pain. She was referred to the hospital emergency department twice during that last week of January. She was placed on prednisone which did produce some improvement and she returned to school although she was unable to play volleyball. The stomach pains had also gotten worse and she was seen by a gastroenterologist who scheduled an endoscopy in the first week of February. The endoscopy did show an irritated stomach but no cause was found even after biopsies were taken. She also complained of headaches and in mid March, she stated she had severe headaches and on the 16th she admitted to having double vision and pain in the right eye. She was admitted in the hospital and a MRI of the Brain was done along with a lot of lab work and a spinal tap. The MRI revealed right cerebral peduncle lesion. The spinal tap was done to pursue other possible reasons for this MRI finding but all tests requested by the infectious disease physician, rheumatologist, neurologist and pediatrician were negative. She was discharged nine days later. In early June she was seen by the endocrinologist who noted that there had been a significant weight loss-fourteen pounds. Not until mid to late June 2008 did she start to show improvement. Eleven months after receiving the vaccine, she has finally begun to put back on some weight; she is no longer having muscle pain or fatigue or stomach pains. Was the GARDASIL the reason for this, no one really knows. But, I am raising this question. What is known is that all the tests that were performed produced no answers and the once positive ANA is now negative. The Brain MRI will be repeated later this year. What is certain is that this now, fifteen-year-old is beginning to show signs of returning to the state of health she was at prior to July of 2007.  9/15/2008 MR received for ER visit 1/31/08 with DX: Systemic Lupus Erythematosus. Chest pain-pleuritic and DOS 3/16-25/2008 with D/C DX: Suspected Autoimmune Disease, r/o Multiple Sclerosis. Multiple Diagnostic Tests beginning 7/25/07 also sent. Pt presented to ER 1/31/08 with c/o chest pain and breathing difficulty. Similar sx earlier in the week, started on Pred. ROS (+) for fatigue and weakness as well as feeling hot and cold. PE (+) for R cervical lymphadenopathy. D/C for outpt f/u. Pt presented 3/16/08 with 2 wk hx of blurry vision, diplopia, gait problems,  bitemporal h/a and sharp pain of the orbits which started 2 days prior to admission. Refered to pain Mgmt team with H/A improvement with caffeine. 9/15/08 MR received from PCP including Rheumatology & GI consults. WCC 7/10/07 with Assessment Well visit, s/p concussion-H/A, hypothyroidism. Recd Menactra and Gardasil.  Seen 11/14/07 with pharyngitis/weakness. Dx with Mono. Seen 12/3/07 with itchy papular lesions. OV 1/9/08 with c/o throat, facial and chest pain. On PE: tender axillary nodes bilat, tenderness to mid sternum and maxillary area and throat hyperemia found. DX:  Pharyngitis, Facial Pain, Axillary Lymphaadenitis. F/U 1/17/08 with worsening sore throat, increased fatigue, aches, chills, chest tenderness wth swelling of the R scapula. DX: chostochondritis. Rheum consult 1/24/08 as above with decreased ADLs, weight loss, temp fluctuations, facial and abdominal pain. Impression: (+) ANA. (+) DS DNA.  Mild facial rash. 1/31/08 Now requiring temporary home school. GI consult 2/14/08. W/u in progress.