Age: 52.0
Sex: F
Vaccine: FLU3
Symptoms: Gait disturbance, Gaze palsy, Headache, Hemiparesis, Impaired driving ability
Clinical narrative: 9/23/2010-10/1/2010 - Cough, headache, sneezing, and fatigue. 9/27/2010 doctor office visit - Diagnosis bronchitis treated with Z pack. 10/4/2010 - Dry irritated left eye with some discharge - treated with ABX eye drops. 10/7/2011 - left eye tremors began. 10/7/2010 - Office visit neurologist. Eye tremors - possible cause fatigue. 10/22/2010 - left sided facial tremors along with left eye tremors, blurred vision. Photophobia left eye. 10/22/2010 - Eye Institute Office visit - Diagnosis chronic dry eye, eye tremor caused by fatigue. Facial tremors - I was advised to see neurologist. Treatment - lubricating eye drops as needed and eye gel at bedtime. 10/28/2010 - Left sided facial paralysis for approximately 30 - 45 minutes. Motor deficits left side, difficulty walking and controlling left arm, Left arm tremors began. 10/29/2010 - office visit neurologist. - Prescription for KLONOPIN 0.5 mg at bedtime and in morning as needed for tremors. Scheduled for MRI brain at medical center. 11/2/2010 office visit neurologist. Advised of INFLUENZA vaccination taken on 9/20/2010. Possible diagnosis- adverse reaction to vaccination. EVP scheduled to demyelination areas seen on MRI of brain to rule out Multiple Sclerosis. 11/4/2010 - office visit - primary physician. Discussed symptoms. Labs ordered. Difficulty with short term memory, unable to drive due to facial tremors and blurred vision. Expressive aphasia. 11/9/2010 - office visit. All symptoms worsening, eyes rolling back with tremors and trying to focus. Advised to see neurologist. Advised to be off work Nov 10, 11, 12, 2010. Possible optic neuritis - office scheduled office visit with DO at eye center. Still unable to drive worsening photophobia wearing sunglasses nearly all the time. 11/10/2010 - evaluated by DO for optic neuritis. 11/12/2010 - office visit. MEDROL dose pack prescribed. 11/13/2010 - Started MEDROL dose pack resumed NUVIGIL, ARTANE, KLONOPIN as prescribed and advised by doc. Uncontrolled shaking over entire body. 11/14/2010 - MEDROL dose pack continued. Discontinued NUVIGIL. Still all over body shaking. 11/15/2010 - Advised by doctor to discontinue MEDROL dose pack. Continue to take NUVIGIL, ARTANE and KLONOPIN. 11/13 - 11/16/2010 - Uncontrollable all over shaking trembling. Skin on face and chest reddened. 11/15 and 11/16 all over body redness. 11/18/2010 - Tremors continue. Febrile. Driven to doctor office. Oral temp in office 100.9, 100.6. Dr contacted neurologist and scheduled appointment for Nov 23, 2010. Z pack prescription written and I was advised that if I did not feel any better to immediately report to medical center ER for further treatment. Severe weakness, still unable to drive. 11/18/2010 - 11/21/2010 - In patient admission to medical center. Labs and MRI of spine and brain. Lumbar puncture, 24 hour urine collection. Carbanazepine 100 mg by mouth 3 times daily prescribed at discharge. 11/22/2010 - doctor visit. Advised to be off work until 12/3/2010. 12/1/2010 office visit. Advised to be off work until 1/3/2011, due to severe fatigue, blurred vision, left sided weakness and facial tremors, short term memory deficits. 12/10/2010 office visit neurologist. Discussed labs, MRI results. Adjusted medications. 24 hour urine testing for MS negative. Unable to identify cause of neurological symptoms. I was advised that l did have active Epstein Barr Virus. Discussed treating tremors with Botox injection by physician. 12/20/2010 - Tremors decreased substantially. Doc contacted and discussed returning to work 12/27/2010. Return to work paperwork faxed to Employee Health Office. Diagnoses at this time idiopathic neurological symptoms, active Epstein Barr Virus, Vitamin D deficiency. Undetermined MRI results subtle foci peri ventricular raising concern for demyelinating plaques in 2 areas. Follow up MRI 6 - 12 months per doc. I continue to have facial tremors when I am fatigues and have difficulty with short term memory. I continue to restrict strenuous activity to avoid these symptoms. I have a scheduled office visit with doctor on Jan 14, 2011 and doctor on Feb 23, 2011. Doctor January 4, 2010.