Age: 34.0
Sex: M
Vaccine: TD
Symptoms: Muscle atrophy, Muscular weakness, Musculoskeletal pain, Neurological examination abnormal, Nuclear magnetic resonance imaging normal
Clinical narrative: Service member reports that in Jan '86 he developed severe pain, numbness and weakness in the left shoulder, arm, and hand that lasted for weeks. He was active duty in the military at the time and medical record documentation supports this report of his symptoms. He believes that he received vaccinations prior to developing these symptoms but vaccination records from that period have been lost. He had diagnostic testing for these symptoms in Dec 86 at a neurosurgery dept and on examination he was found to have "complete atrophy of the supraspinatous and infraspinatous muscle group". Impression was "...either an isolated nerve injury to the supraspinatous nerve...or a form of muscular dystrophy." An EMG study performed subsequently at a hospital was consistent with brachial plexitis. There was no specific treatment indicated. Pain symptoms diminished over time and the patient performed his own P.T. which decreased, but did not totally resolve the weakness. Service member left active duty and remained active in service. In 1999 while preparing for deployment, he received the tetanus/diphtheria vaccination on 1 Mar and the typhoid, yellow fever, hepatitis A and meningococcal vaccines on 6 April 99. It is unknown in which sites individual vaccinations were placed. Following these vaccinations he developed additional numbness in the left 4th and 5th fingers along with the loss of fine motor skills in the left arm. Service member rates the decrease in motor function in the left arm from a pre-vaccine level of 10/10 to 3/10 post vaccination. He had difficulty with the manipulation of tools and writing within his MOS and began dropping items. He also states he developed intermittent tingling and numbness in the left foot. He states he did not report this exacerbation of symptoms but their documentation appears on a Assessment in Sept 00. He did not receive evaluation or treatment for the symptoms but again performed his own P.T. and regained the motor function back to a 6/10. In Jan 2003 he received the meningococcal vaccine in preparation for deployment. After this immunization he reports he developed pain, burning in the left medical bicep and numbness of the left arm. In Sept 03 he received neurologist evaluation and was diagnosed with a "post inoculation immune mediated brachial plexopathy and/or cervical radiculopathy." His EMG demonstrated a left mid/lower C7 cervical radiculopathy involving the triceps. MRI of the cervical spine was negative as well as MR of the chest with attention to the left brachial plexus. Currently he has residual weakness and loss of dexterity in the left arm and hand that minimally affects functioning since he is right hand dominant. The paresthesias persist also in the left foot manifesting as a severe burning sensation in the 3rd and 4th toes, usually at night while trying to sleep.   8/14/09 Medical records received 1/27/1986 to 8/3/09. Assessment: Brachial neuritis. Presents with recurring fatigue, numbness in limbs, tightness in neck, headaches. Loss of dexterity left hand. GERD. Flu-like symptons. Heaviness left lower extremity. Numbness left foot around 3rd and 4th toes. Aching and burning left biceps. Weakness and atrophy, diminished deep tendon reflexes right upper extremity and left scapular musculature. Numbness left hand.