Age: 55.0
Sex: F
Vaccine: LYME
Symptoms: Back pain, Bacterial infection, Blood disorder, Bone disorder, CSF test abnormal
Clinical narrative: This case was reported by a lawyer and described the occurrence of severe cognitive deficiency in a female subject of unspecified age who was vaccinated with Lymerix for prophylaxis. A physician or other health care professional has not verified this report. On an unspecified date the subject received unspecified dose of Lymerix (unknown). At an unspecified time after vaccination with Lymerix, the subject experienced severe cognitive deficiency, memory loss, fatigue, stiffness and pain throughout her joints and muscles, flu-like symptoms, headaches, possible neurological injuries, possible autoimmune disease, and decreased activities of daily life. At the time of reporting the outcome of the events was unspecified. This information was received via a statement of injuries. Follow up information was received on 09 January 2007 via medical records. Medical history included positive Lyme serology, hypertension, irritable bowel syndrome, rare cardiac palpitations, migraine and tension headaches, fatigue, osteopenia, and acute onset of polymyalgia rheumatica following hepatitis B vaccine in 1991. In 1998 to 1999, she developed intermittent retro orbital headaches different from her usual headaches, with associated arthralgias, fatigue, episodes of dropping things due to transient loss of hand strength, and decreased cognitive function. On an unknown date, she was diagnosed with severe excessive daytime sleepiness compatible with narcolepsy or idiopathic hypersomnia. In February 1999, she was evaluated for excessive fatigue, debilitating constipation, constant back pain, problems with obsessive compulsive disorder particularly counting, possible underlying depression, and prominent chest vessels. In March 1999, the subject presented with a rash, itching and hives that was clearly an allergic reaction. The subject, a 55 year old female, was vaccinated with Lymerix on 23 April 1999, 21 May 1999 and 21 June 1999. In September 1999, she reported that she experienced excessive fatigue, and noted that she had stopped Prozac. In February 2000, the subject presented to the emergency room with palpitations and several sustained episodes of flutter, presumed to be supraventricular tachycardia. In April 2000, the subject was evaluated for continued fatigue, which was noted may represent a failure of her medication plus side effect, and we will take her off calcium blocker and put her on Lisinopril. In January 2001, treatment with Prozac was re initiated for treatment of overwhelming fatigue with possible underlying depression, and by May 2001 she noted that she had more good days than bad days with Prozac. In the summer of 2001, the subject reported that all her symptoms resolved and she felt completely normal with no change in her medications, which coincided with a sexual, termination of this relationship, she reported that symptoms returned. In a letter dated 26 June 2001 she stated that she suspected depression is the root of my debilitating fatigue. In August 2001 she was examined for headaches, possibly secondary to hypertension, but atypical migraine cannot be ruled out. Treatment included Motrin. In March 2002, she was diagnosed with Lyme disease, with symptoms including fatigue, neurasthenia, cognitive deficit, and minor dermatographia. In August 2002, treatment included doxycycline, the subject continued to complaint of cognitive problems including difficulty comprehending news prints or reading books and poor recall. On 02 October 2002, the subject was evaluated by a neurologist for a complaint of a three year history of extreme fatigue, impaired mental concentration,difficulty with visual and mental focus, a sense of shakiness internally, and difficulty remaining alert. Additional symptoms included lightheadedness, dizziness, nonspecific headache, and aching through out the limbs with a sense of pitting of the skin. Impression was of subjective cognitive decline and fatigue/sleepiness, with recent tests raising the question of possible narcolepsy. In September 2002 complaints included back pain, with bilateral sciatic tightness described as shooting pains, in the right buttock down to the posterior lateral thigh and calf. She reported receiving "black Cohash" with improved cognition. In November 2002, she was evaluated for multiple non specific symptoms including aches, pains, and fatigue, assessment included possible underlying fibromyalgia. A bone scan showed Osteoporosis and increased osteopenia. On 07 November 2002, she was evaluated by a rheumatologist who stated I do not see any fulfillment truly of an autoimmune disorder. The following day, neurology consultation resulted in no neurologic diagnosis to explain the symptom complex. In March 2004, the subject presented to a neurologist with complaints of mental and physical fatigue, insomnia, pain and stiffness, and cognitive decline starting a few years ago. Diagnostic test were positive for Lyme disease, and notes indicated last course of antibiotics January 2003. In May 2004, she reported improved memory following initiation of Co enzyme Q10. In June 2004, Lyme disease was being managed with Biaxin and Plaquenil. She was also receiving Cortef for polymyalgia rheumatica and acupuncture for insomnia, and reported complete resolution of myalgias since adding magnesium to her diet. Assessment included fibromyalgia/chronic fatigue. On 01 December 2004, the subject underwent a cerebral blood flow study for indications of Lyme disease and Lyme encephalopathy. Examination revealed patchy decreased blood flow to vertex. On follow up, the subject reported that she was placed on disability on an unknown date. This case was also assessed to be medically significant by manufacturer (OMIC). During the course of her illness, the subject received multiple homeopathic herbal medications including Glucosamine Chondroitin, Co enzyme Q10, black Cohash, mild thistle seeds, flax oil, evening primrose oil, red clover extracted, fermented soy, B complex and energy infusion, probiotics, and L Theanine. Possible narcolepsy/idiopathic hypersomnia was treated with various stimulants. In November 2002, she was noted to have grade II cardiac murmur. She was also diagnosed with hypothyroidism, presumed supraventricular tachycardia, and hyperlipidemia. these were assessed to be incidental findings upon the course of review of medical records.