Sex: F
Vaccine: LYME
Symptoms: Chronic fatigue syndrome, Clostridium difficile colitis, Cognitive disorder, Confusional state, Decreased activity
Clinical narrative: This case was reported by a lawyer and described the occurrence of arthralgias 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 experienced arthralgias, myalgias, numbness and tingling, eye problems, headaches, cold feeling in extremities, memory loss, loss of concentration, fatigue, dizziness, confusion, sweats, neck locking, jaw locking, stabbing pains, rheumatologic, neurologic and/or cognitive impairment of an autoimmune, immune-mediated, or other mechanism, all reportedly cause by vaccination with Lymerix. She also experienced decreased activities of daily life and decreased ability to participate in recreational activities. 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 April 2007 via medical records. The subject was a  female in her forties. On an unknown date, the subject reportedly developed vertigo and encephalopathy. She indicated that she developed vertigo and confusion which worsened. According to internal medicine physician's notes, she was evaluated weekly between 02 June 2003 and 13 August 2003 for a diagnosis of Lyme disease with associated physical findings of encephalopathy and fatigue. At the time of the initial examination, the subject reported fevers, chills, and sweats since June 2002, ear ringing and ear pain, and tremor since May 2003. Lyme symptoms of approximately one year duration, including dizziness, heart palpitations, fever, sweats, chills, fatigue, memory loss, headache, joint and muscle pain, blurred vision, and difficulty with speech. Treatment up to that time included Zithromax, Bextra, and Effexor; Zithromax was discontinued after the subject developed associated gastrointestinal symptoms. The physician expressed the opinion that the subject was "suffering with an active infection of Borrelia Burgdorefi" with repeated positive testing, and oral antibiotic therapy failure. In July 2003, a diagnosis of osteoarthritis was identified. On 25 July 2003, she received her initial dose of intravenous Rocephin via a peripherally inserted central catheter (PICC). In September 2004, she presented with a chief complaint of vertigo for a few months duration, and Antivert was prescribed. On 01 March 2005, she was evaluated by an orthopedist with complaint os whole body pain, Lyme disease, fibromyalgia, and chronic fatigue syndrome, with chronic pain and insomnia. She reported previous treatment including antidepressants, Lidoderm, and cervical injections, and at the tiem pain was poorly controlled and Flexeril. Physical examination revealed "greater than 11/18 fibromyalgia points bilaterally above and below the waist:, with an otherwise normal neurologic examination. Impression was that she fulfilled the criteria for fibromyalgia, and trial of Skelaxin, Zanaflex, and Ambien were initiated. According to physician's billing summaries, the subject was evaluated on 02 June 2003, and was diagnosed with arthralgia (multiple sites), fatigue, encephalopathy (unspecified), and encephalopathy (unspecified). In March 2004 she was evaluated for Lyme disease, myalgias and myositis. In September 2004, she experienced dizziness/giddiness. On 16 June 2005, the subject was evaluated by an orthopedist following her work place injury in May 2005. At that time, she was assessed with degenerative disc disease and fibromyalgia by history, in addition to injury associated events of lumbosacral strain and possible left knee sprain. Examination did not reveal focal disc herniation, and it was noted that the degenerative changes identified by magnetic resonance imaging were chronic. It was also noted that the subject's complaint of numbness in the arms and legs was "difficult to explain on the basis of the trauma". Treatment included physical therapy and Naproxen. This event of encephalopathy was assessed to be medically significant by manufacturer. On an unknown date in 2000, the subject was hospitalized for a right thyroid mass. The subject also experienced abnormal weight gain, hyperlipidemia, irritable bowel syndrome, rectal bleeding with possible hemorrhoids, clostridium difficile colitis due to long term antibiotic use, and chest pain. On 17 May 2005, the subject experienced an injury to her lower back, left knee, and chest when assisting a subject who had collapsed in the course of her employment in home health care. Symptoms included acute onset of lower back and chest pain, and hand numbness. She was assessed as a having a lumbar sprain/lateral radiculopathy with bilateral paresthesias in the feet. The subject subsequently initiated a workman's compensation claim for a herniated disc. These were considered to be incidental findings upon medical record review.