Age: 54.0
Sex: M
Vaccine: LYME
Symptoms: Arthritis, Depression, Eye disorder, Fatigue, Nervous system disorder
Clinical narrative: On an unspecified date the pt received the Lymerix vaccine.  Subsequently, he experienced electrical shock sensations in his nerves down his legs, photosensitivity, achiness, fatigue, and depression. Additionally, an ophthalmologist found white blood cells in the pt's eyes. An ER or MD visit was required. An MRI and EMG were done.  The most recent information received on 3/13/00, reports the condition of the pt as ongoing. A 15-day follow up report received 01/03/2001 adds: Report 2000007085-1 describes muscle spasms in a 54 year-old male who received Lymerix for the prevention of Lyme disease. This report was received from the daughter of the vaccinee and from a lawyer with follow-up medical records and has not been verified by a physician or other health care professional. Reportedly, the pt is allergic to Tylenol. Medical history includes low back pain, dermatitis (seborrhea), poor close-up vision, and knee and hemorrhoid surgery. His father has arthritis.  On 06/29/1999 and 08/04/1999, the pt received his 1st and 2nd doses of Lymerix.  Six days following dose 2 of Lymerix, on 08/10/1999, the pt reportedly started having pain in his wrists, flu-like symptoms and a sore spot on his left ribcage under his left arm for 7-10 days. A chest X-ray was negative. Subsequently, he experienced electrical shock sensations in his nerves down his legs, photosensitivity, achiness, fatigue and depression. Additionally an optometrist reportedly found "white blood cells were in the pt's eyes". In Sept 1999 he developed pain in his left hip joint which was periodic, and also a weakness in his leg muscles. In Nov 1999 he first noticed weakness and had episodes of foot pain. In mid-December his hip pain worsened, so he went to his family doctor who did an X-ray which showed slight "osteo", but according to his physician, was not enough to be causing his pain. At this time, the pt started noticing activity-related thigh pain. He was treated with celecoxib (Celebrex). Through January 2000 he continued to get worse. He went to an orthopedist and underwent an MRI (which was negative). He then developed a burning and aching in this thighs/hamstrings, and flu-like chills that lasted several days at a time. On 01/05/2000 the orthopedist stated that the pt initially had right hip pain following a hemorrhoidectomy procedure. The pt was not sure if his physicians put him in an unusual position or not, but he had primarily lateral right hip pain following this. That seemed to resolve, and then he developed some low back pain following this for awhile, although this too resolved. He then injured his left hip when he was standing on a chair in Sept 1999. At that point as he stepped off, he caught the high back of the chair directly in his left groin, not involving his genitals. From that point forward he has had some sharp pain in his left hip primatily with positioning of the hip in adduction past the midline or internal rotation of the hip. The physician stated that the pt really did not have a great deal of pain necessarily with weight bearing. He denied any numbness or tingling with the left lower extremity. He did not have any increased pain with coughing or defecation. He had been taking an anti-inflammatory without significant relief. The pt did not feel that the pain had improved markedly since his injury. Impression: an unusual deep groin pain involving his left hip which is related more to position than muscle activation. At the end of January 2000 the pt experienced severe muscle spasms in both thighs. The next morning, his family physician referred him to neurologists, rheumatologist and psychiatric counselors. 02/04/2000: neurologist visit: the pt stated that he had muscle spasms and back pain, and was evaluated. The pt had leg muscle concerns in the last week with prior back, leg and hip pain. There was no antecedent trauma. Course has been one of improved spasms. The spasms started in the hamstrings and spread to the entire thighs bilaterally. The spasm can include burning or tingling. Severity is described as "awful" or "maddening" and limited what he did. He may have had increaseing or precipitating factors with exertion but no diurnal pattern or increase with change in temperature, cough, sneeze or valsalva. He improved with a warm bath, as well as celecoxib (Celebrex) and cyclobenraprine HCl (Flexeril). He was worse with exertion, so PT treatments were stopped. He might have had dysphagia (but only on awakening and due to a dry mouth and throat), and he had bilateral hip pain. On examination, he denied dysphagia, weakness, swelling, symptoms in upper extremities or cranial nerves, incontinence, or change in color or temperature. He had generalized weakness with "soreness from the spasms" and his muscles felt "rubbery". The pt reported having chills, weight change, night sweats, fatigue, visual flashes, decreased appetite, diarrhea, excessive thirst, frequent urination, joint pain, forgetfulness, tremor, hot flashes, depression, nervousness/tension, difficulty concentrating, disturbed sleep and mood changes. The neurologist reported that the most likely diagnosis was physiologic cramps after increased exertion in PT. However, an extensive list of differential diagnoses was provided which included 1. localized spasm due to spinal or nerve root process 2. central disorders including infections such as tetanus or stiff-man syndrome, spasticity secondary to structural lesion including MS 3. peripheral nerve disorders 4. muscle disorders 5. neuromuscular conditions. Assessment: muscle spasms with weakness. Plan: check EMG (electromyograph) with NCV (nerve conduction velocities) of the back and legs 2. Discontinue Lamisil: a small percentage of individuals may have musculoskeletal complaints on this medication, stated physician. 3. Continue present treatment otherwise (e.g. Tylenol and cyclobenzaprine). 4. Consider dependent on course biopsy of muscle and nerve. 5. The neurologist will defer to the primary physician concerning possible further evaluation and/or treatment of the ANA titer. 6. Return to clinic in 3-4 weeks. Nerve conduction studies and EMG needle examination were performed. See laboratory results section for details. He has continued to worsen and has been out of work since 01/30/2000. His eyesight is now extremely photo-sensitive (he must wear sunglasses and a hat in order to be able to go out in the sunlight) and his hearing is also very sensitive. 02/15/2000 (rheumatologist visit). The physician believed that the pt may be having some inguinal pain from early osteoarthritis. The X-ray was not terribly remarkable. However, there were some subtle changes that might explain his discomfort in the groin. The physician asked the pt to stop celecoxib (Celebrex) and try rofecoxib (Vioxx) for a week or two. The physician believed that the ANA result was probably a nonspecific finding. He did not find any evidence of muscle weakness or other automimmune disease on the pt's physical exam. He believed that the pt was suffering from depression that has not fully responded to Prozac. Impression: 1. Probably early osteoarthritis, left hip. 2. Depressive reaction. 02/25/2000 physician states that the pt had acutely worsening symptoms of anxiety and depression, including changes in his sleep, anhedonism, and not wanting to dress or shave at times. He reported that he was uncomfortable being around windows and mirrors and "I don't feel right". "My thought processes are not right". He had anxiety attacks with feelings of hopelessness, extreme nervousness, weight loss, fatigue, weakness, extreme thirst, sleeplessness, burning and aching, red palms, no interests, anxiety and hip pain. The location of the muscle spasm remained in the hamstrings and spread to the entire thighs bilaterally. In addition, his left leg felt "wobbly when I walk". The quality remained a spasm, burning or tingling. His symptoms improved with a warm bath, as well as celecoxib (Celebrex) and cyclobenzaprine hydrochloride (Floxeril). His symptoms are worse with exertion. Assessment: positive ANA evaluated by rheumatologist. On 03/01/2000, the pt first noted the sensitivity to light and has since become progressively worse. He has also experienced tinnitus, vertigo and rigidity. The ophthalmic examination appeared essentially normal. He was treated on 03/06/2000 for muscle pain, generalized aches, joint pain, blurred vision, depression and paresthesias. The pt had experienced a 20 pound weight loss during the past 3 months. Since January 2000 his appetite has been poor and he felt perisitently nauseated. The pt was formerly an active outdoorsman and athlete who worked for the Park Service. The pt denied headache, memory problems, or any difficulty with normal thought processes. He does acknowledge marked anxiety and depression and he has multiple somatic complaints. His medications on 03/06/2000 were fluoxetine (Prozac), celecosib (Celebrex) and rofecoxib (Vioxx). Impression: The pt has multiple somatic complaints and normal neurological examination. There is no evidence of muscular disease on exam. The pt had a prominent anxiety component. There was no evidence that the pt has a motor neuron disease, such as ALS. He was treated on 03/24/2000 for arthritis, fatigue and joint pain. The physician stated that the pt has complained of arthritis for 8 weeks which developed in his left hip and now involved both hips and both knees. The pt was now on disability. The pt complained of fasciculations in his muscles. He has had some difficulty sleeping. # people who were close to him died recently. He has multiple bodily complaints and muscle aches and joint aches. He was currently taking celecoxib (Celebrex) 20 mg qd, rofecoxib (Vioxx) mg qd, and zolpidem hemitartrate (Ambien).  03/27/2000: Physician stated that the pt has improved from the standpoint of his eyesight, energy level and headaches. An ophthalmologist evaluated the pt and stated that he did not have iritis. Assessment: photophobia and phonophobia: ongoing. Muscle spasms with weakness: ongoing. No neuromuscular concerns identified. Sleep disturbance of "I just can't go to sleep or stay asleep": ongoing. Anxiety and depression: ongoing. Test results out of range: MRI of the lumbar spine (02/09/2000): far right lateral disc herniation without nerve root impingement at L4-5. ANA 1:80 speckled. EMG with complex repetitive discharges in leg and paraspinal muscles (but no NRC per MRI). April 2000: A Western blot revealed the presence of IgM 23, 39 and 41 and RgG bands 93, 66, 58, 45, 41, 39 and 23. He is now taking cefuroxime axetil (Ceftin) and clarithromycin (Biaxin). 05/01/2000 live cell fluorescent antibody technique for Borrelia burgdorferi-positive. 05/19/2000 physician visit: current medications: rofecoxib (Vioxx), mirtazapine (Romeron) 30 mg for depression, zolpidem hemitartrate (Ambien) 2 at HS for insomnia, valacyclovir hydrochloride (Valtrex) 1 bid for Epstein-Barr virus, liothyronine sodium (Cytomel) for fatigue, and vitamin B12 1000 mcg IM-left deltoid for B12 deficiency. The pt complained of some testicular tenderness, fatigue ("almost chronic") chest pain around sternum (none while playing golf), ringing in ears, improved photophobia ("but still sensitive"), mild tingling/numbness in lower legs and feet, red throat and depression. This case is considered serious because the pt has been disabled since he has been out of work. Info received on 12/19/2000 reports the condition of the pt an unknown. A 15-day follow up report received 03/23/2001 adds: (Medical history includes) torn labrum right shoulder (1994), torn biceps tendon left shoulder (1994), torn cartilege right shoulder (1991), headaches since at least 1988, stiff joints since at least 1988, intermittent aching of joints and swelling of knee following exercise on hard surface, sinus infections, "cartilege injury of the sternum", "joint weakness", urinary incontinence, right knee surgery (1964), chronically prolapsed bleeding external and internal hemorrhoids (01/19/1994 to Feb 1999). ... Info received on 03/08/2001 reports the condition of the pt as unknown. A follow up report received 4/4/2001 adds no new info. A follow up report received 4/20/01 adds: Info received on 04/16/2001 reports the condition of the pt as unknown.