Age: 17.0
Sex: F
Vaccine: HPV4
Symptoms: Epstein-Barr virus test positive, Granulocyte count increased, Laboratory test normal, Mean cell volume increased, Nuclear magnetic resonance imaging abnormal
Clinical narrative: Information has been received from a physician concerning a 17 year old female with asthma who was vaccinated with GARDASIL. In November 2006, the patient experienced paraethesias of the left thumb, left hand and right forearm and was hospitalized. On an unspecified date the patient experienced anxiety and sore throat. On 14-MAY-2007 the patient experienced syncope, paresthesias of the left hand, right fingers and right toes and vomiting. The patient sought unspecified medical attention. On 15-MAY-2007 head computed tomography showed possible low attenuation of the region of the left occipital lobe. This may represent a chronic area of old infarction. Recommend magnetic resonance imaging (MRI) to further evaluate. On 15-MAY-2007, the brain MRI showed multiple periventricular white matter lesions, tube which demonstrated enhancement following contrast administration. Findings may be related to an active demyelinating process such as multiple sclerosis versus a post viral acute disseminated encephalomyelitis. Correlation with cerebrospinal fluid was recommended. On 18-MAY-2007 cerebrospinal fluid (CSF) cytopathology performed for a history indicating vertigo, was negative for malignant cells. There was rare clusters of small lymphocytes. Enterovirus shell viral culture indicated no virus was detected. On 18-MAY-2007 complete blood count with differential was within normal limits except for mean corpuscular hemoglobin (MCH) was 31.5 and granulocytes were 71.9. Antinuclear antibody screen, rheumatoid factor, sedimentation rate, component C3 test and component C4 test were within normal limits. A complement total CH50 was 64, Lyme AB screen with reflex western blot showed no detectable antibody, serum IGG was high at 1656 and a miscellaneous fatty acid profile was within normal limits. Serum Borrelia burgdorferi IgM Western blot antibody and serum Borrelia burgdorferi IgG Western blot antibody tests did not detect antibodies. CSF Myelin Basic Protein was negative. However, the oligoclonal IGG bands showed that the patient had two well defined gamma restriction bands that are not present in the patient's corresponding serum sample. These bands indicate abnormal synthesis of gammaglobulins in the central nervous system. This finding is supportive evidence of multiple sclerosis, but should be interpreted in conjunction with all clinical and laboratory data pertaining to this patient. The immunoglobulin G synthesis rate was within normal limits. On 19-MAY-2007 Cervical and thoracic spine MRI results indicated a single focus of increased signal in the posterior portion of the spinal cord at C5, consistent with demyelinating disease. On 04-JUN-2007 serum Epstein-Barr viral capsid antigen (VCA) immunoglobulin G antibody and serum Epstein-Barr virus nuclear antigen immunoglobulin G antibody tests were positive. Serum Epstein-Barr viral capsid antigen (VCA) immunoglobulin M antibody and Epstein-Barr virus antibodies early antigen tests were negative. 05-APR-2008 repeat MRI showed new enhancing lesion in the left peri-atrial white matter, consistent with an inflammatory demyelinating plaque with a mild amount of surrounding edema. Interval regression of a small non-enhancing plaque in the subependymal white matter superior to the right lateral ventricle. Pattern of disease is otherwise unchanged. The faintly visualized lesion in the cord at C4-5 without significant change. No other definite cord lesions are identified. No abnormal enhancement with the cervical or thoracic cord. On 06-MAY-2008 miscellaneous testing for Neuromyeltis Optica Autoantibody, IgG was negative. The reporting physician considered paraesthesias of the left thumb, left hand, right forearm, right fingers and right toes, syncope, vertigo, and the multiple periventricular white matter lesions to be disabling, prolonged hospitalization and other important medical events. Additional information has been requested. All medical records are available upon request.