Age: 44.0
Sex: F
Vaccine: MMR
Symptoms: Activities of daily living impaired, Arthralgia, Bed rest, Brachial plexopathy, Carpal tunnel syndrome
Clinical narrative: Information has been received from a case in litigation from a physician via legal documentation referring to medical records, concerning an approximately 44 year old female patient who on 03-JUL-2007 was vaccinated with a dose of MMR II (expiration date 15-MAR-2008). Her adverse event onset was the next day (04-JUL-2007). She never felt well after receiving the vaccine. Approximately one week after receiving the vaccine, she complained of severe joint pain that was debilitating enough that she could not work, mild rash, fever at night, blister on her lip, and fatigue. She was seen in emergency department on 12-JUL-2007, and advised to remain home and rest for one week. On 12-JUL-2007 she was also diagnosed as having an "adverse reaction to MMR". The notes from this visit also reflected:" had MMR injection one week ago. Now has arthralgia, joint pain and rash." Moreover, according to the administered nurse, she noted that the practitioner concurred that the patient's fever, rash and severe joint pain were vaccine-related. The patient presented to the emergency department on 16-JUL-2007. Her discharge diagnosis was joint pain status post MMR vaccination. The patient was noted to have aching pain in her joints on an level of 6 out of 10 provoked by the MMR II vaccination. The patient presented again to the emergency department on 18-JUL-2007. The patient was prescribed CELEBREX 200 mg p.o. daily, REGLAN p.o. prn and MOTRIN p.o. . On 26-JUL-2007 the patient saw rheumatologist for an initial office consultation. The physician's impression was polyarthralgia, suspect reactive to MMR II shot. The physician also noted that the CELEBREX did not help, and recommended no work until further notice. On 08-AUG-2007 the patient returned to see the rheumatologist. The physician noted that the patient still had a fair amount of pain in her wrists and arms. The impression was arthralgia, supposedly from the MMR II shot. On 23-AUG-2007 the patient saw the rheumatologist again, who noted the patient's persistent joint pain, and recommended 90-day disability from work. The physician also noted that the patient seemed to have symptoms of carpal tunnel syndrome, with weakness, pain and some paresthesias of the hands. The patient also had elbow pain of tendinitis nature, more on the right side. The physician's impression was (1) polyarthralgia, presumably related to the MMR vaccination; (2) development of possible carpal tunnel syndrome and bilateral elbow tendinitis. The physician advised the patient to see a neurologist for nerve conduction studies of the upper extremities to check out all the carpal tunnel syndrome possibilities. On 11-SEP-2007 the patient presented to neurologist, complained of pain, swelling and paresthesias in both hands, right much greater than left. The patient reported that her symptoms began after the vaccination on 03-jul-2007 in the emergency room. One week after the injection, she developed fever, rash and edema of her joints. The symptoms lasted for about four weeks. Her current symptoms continued to wake her up at night. The patient stated she could no longer blow dry her hair because her right arm became heavy and she had to put it down. She also noted increased symptoms with writing and the use of a computer mouse. The patient also noted numbness down the arm into the fourth and fifth digits bilaterally. The physician also conducted an EMG during that visit. On 10-OCT-2007 the neurologist prescribed physical therapy for the patient. The physician also noted that the patient continued to complain of right upper extremity pain/paresthesis, independent with approximately 50% of activities of daily living, and unable to lift or perform overhead movements, Her pain level was also noted to be 5 out of 10. On 19-OCT-2007 the neurologist recommended the patient should remain off work for the next 90 days, and diagnosed her with brachial plexitis and thoracic other syndrome. Pursuant to the follow-up examination by the neurologist on 08-FEB-2008, the patient was still on a leave of absence from work, and had not responded to any medications. The physician's assessment was brachial plexitis likely to take 12 to 18 months post occurrence for recovery. The neurologist's note on 08-APR-2008 stated that the patient had tried physical therapy without benefit. She had also been tried on LYRICA and other agents from neuropathic pain without much improvement as well. She continued to have some swelling of her right hand which was relatively mild. She noted that a marked increase in pain and muscular spasm with the use of her right upper extremity. This included writing or other activities which were primarily dexterous in nature in addition to those which required gross motor strength. She recently tried to do some exercise on a treadmill and noted that simply walking on the treadmill moving her arms back-and-forth will cause a great deal of pain requiring her to stop. She experienced sensory symptoms down the arm primarily into the fourth and fifth digits. She didn't really notice any significant motor weakness. She was now 10 months out since her exposure and had had some mild improvement. Because of the limitations noted above, she stated she was no longer able to work as a nurse in the emergency room or impatient care and was going to have to seek training for alternative employment. The physician had told the patient that recovery from such events generally take 12 to 18 months. It might also be incomplete. The patient had inquired about doing some more physical therapy but the physician told her until her pain improved, this was not really feasible. The neurologist's note on 16-JUL-2008 stated that at that time the patient was over one year since the onset of her symptoms. She continued to have neuropathic pain of the right upper extremity with swelling of the hand. She had not responded to physical therapy, LYRICA or CYMBALTA. She had difficulty holding objects in her hand due to pain and would drop things. Being one year post onset without significant change in her symptoms, makes it very unlikely that they will change. The neurologist thought the patient was at maximum medical improvement and would continue to have chronic pain of the right upper extremity on a neuropathic basis. Because of her injury the patient had been unable to obtain employment despite making over 70 job applications. The neurologist's note on 06-NOV-2008 stated in pertinent part that the patient had failed multiple therapeutic agents and her pain would in fact be chronic as it had not improved any after more than 14 months. A board certified neurologist and psychiatrist who evaluated the patient and stated in his September 25, 2008 report that the patient had complex regional pain syndrome, type one, which was directly caused by the MMR II (expiration date 15-MAR-2008) vaccinated on 03-JUL-2007. The physician also ruled out the possibility of other potential causes of the injury by stating the patient had not had any prior recent vaccinations, toxic exposures, foreign travel, or unexplained fevers or other illnesses in the past several years prior to the 2007 MMR II (expiration date 15-MAR-2008) injection. According to the physician, per the Life Care Plan of 19-OCT-2008, the patient would required 37 years of medical treatment in the future related to her MMR II (expiration date 15-MAR-2008) vaccination. The physician also opined that the patient's future life span was not reduced by the very nature of the injury and its sequelae. Polyarthralgia, complex regional pain syndrome, brachial plexitis and thoracic other syndrome were considered as disabling. Additional information is not expected.