Age: 1.05
Sex: M
Vaccine: MMR
Symptoms: Hearing impaired, Laboratory test abnormal, Otitis media, Sleep apnoea syndrome, Social avoidant behaviour
Clinical narrative: Information has been received from medical records regarding a case in litigation concerning a 13 month old male pt with a history of acrocyanosis (26Nov96), sniffles (31Dec96), bronchiolitis (02Feb97), diarrhea (02Feb97), and frequent attacks of ear infections (otitis media 06Aug97) and otitis externa (Oct 1997) who on 10Dec1997 was vaccinated with his first dose of  measles virus vaccine live  (Enders-Edmonston) (+) mumps virus vaccine live (Jeryl Lynn) (+) rubella virus vaccine live (Wistar RA 27/3). On 10Dec97 the pt was referred urgently to an Audiologist because his mother was concerned that he was not responding to sound. His first dose of measles virus vaccine live  (Enders-Edmonston) (+) mumps virus vaccine live (Jeryl Lynn) (+) rubella virus vaccine live (Wistar RA 27/3) was given then on the same day. On 20Jan98 the pt was treated with erythroped suspension, 125mg/5 ml 5ml bd 140 ml. On 23Feb98 the audiological assessment indicated a diminution of hearing and the presence of middle ear dysfunction and catarrhal problems. It was reported that on this date the pt had an attack of otitis media. Also on this date, the pt was referred to another Audiologist due to concerns about his hearing level and delayed language development. On 25Feb98 it was reported that the pt was given a second dose of measles virus vaccine live  (Enders-Edmonston) (+) mumps virus vaccine live (Jeryl Lynn) (+) rubella virus vaccine live (Wistar RA 27/3) in error. On 17Mar98 the pt was referred to an Ear, nose and throat (ENT) specialist. On 01May98 the pt was assessed by another Audiologist and tympanometry indicated the presence of middle ear effusions. The Audiologist indicated that the pt's mother felt that he did not hear well at all. She reported that she had to shout very loudly at home in order to get his attention, and that he seems to be in a world of his own and did not react at al. It was reported that he had no speech as yet and was making no babble sounds. The Audiologist stated that her results would suggest that the pt has basically good hearing, but that it probably fluctuated according to the condition of his middle ears. She further stated that there was obviously considerable concern about his lack of speech, but that her impression was that it was not totally due to hearing problems and needed to be investigated separately. On 06May98 the pt was seen by the ENT specialist who diagnosed mild bilateral glue ears. On 30Jun98 the pt was treated with phenergan elixir, 5mg/5ml 2.5ml m 5-10ml n 3 100ml. On 22Oct98 the pt was hospitalized for a day procedure and had bilateral grommets inserted. In Nov 1998 the pt had further referrals (speech therapy, audiology) because of concerns about his communications, as this was being done by gesture and grunts. At an ENT follow up visit on 02Dec98, his mother reported that the pt improved dramatically and was becoming increasingly aware of his surroundings since the grommet insertion. On 09Jan99 the pt was treated with cephalexin syrup, 250mg/5ml 5ml tds 100ml. On 16Feb99 the pt was treated with oilatum emollient 500ml. On 28Apr99 the pt was seen by a pediatric specialist who stated that the pt had severe communication difficulties and some autistic features. She indicated that the pt's mother was clearly anxious about some of the autistic features and the relationship with measles virus vaccine live  (Enders-Edmonston) (+) mumps virus vaccine live (Jeryl Lynn) (+) rubella virus vaccine live (Wistar RA 27/3). After reviewing her notes she felt it seemed the pt had a problem with his hearing and speech before his second vaccination with measles virus vaccine live  (Enders-Edmonston) (+) mumps virus vaccine live (Jeryl Lynn) (+) rubella virus vaccine live (Wistar RA 27/3). In July, 1999 the pediatric specialist concluded that the pt had communication difficulties showing autistic tendencies. On 15Jul99 the pt was treated with hydrocortisone cream 1% bd 15 grams. On 21Jul99 the pt was treated with senna syrup 7.5mg/d ml 2.5 5ml nocte 100ml. In Oct99 the pt was seen by a consultant psychiatrist. At that meeting the pt's mother informed him that she felt her son did not make much progress with his language, was withdrawn and fearful in a lot of situations since his second vaccination with measles virus vaccine live  (Enders-Edmonston) (+) mumps virus vaccine live (Jeryl Lynn) (+) rubella virus vaccine live (Wistar RA 27/3). The psychiatrist's conclusion was that the pt had communication difficulties but currently did not fulfill all the criteria for autism. The pt's mother reported that he had been suffering from diarrhea since approx Jan99. She stated that he used to be constipated and that there were days when he did not open his bowels and then there were days when he was going two or three times. Upon physical examination it was felt the pt might be constipated, and this was confirmed by abdominal x-ray. By March of 2000 the pt was receiving speech and language therapy and had made progress attending a play group, but as yet had received no firm diagnosis. On 27Jun00 the pt's tonsils were slightly enlarged. On 30Aug00 during an ENT follow up the pt's mother stated he snores loudly and stops breathing at night. Upon examination, both eardrums showed signs of glue. The tonsils were huge, almost meeting each other. A sleep study was arranged for the pt. On 11Dec00 the sleep study results were completely normal. However, it was noted that this did not completely exclude obstructive sleep apnea. As of 09May01, the pt's tonsils were of moderate size and both tympanic membranes looked entirely normal. The pt was referred for further audiologic testing. On 15Aug01 tympanometry and examination indicated bilateral mobile tympanic membranes with no evidence of middle ear effusions. On this date it was reported  that since Mar2001 the pt's speech had begun to progress slowly and that he was no able to say a few recognizable words. On 13Feb02 a consultant psychiatrist indicated that the pt's rigid behavior was becoming more of a problem, and that he also had a lot of inappropriate affect and hand mannerisms that were becoming more evident now. He also indicated that there were ongoing problems with sleep patterns and toileting difficulties. It was reported that in the past when he was assessed it was felt  that his difficulties were predominately due to his underlying language impairment but on further information from other professionals it seems he had more problems with social relationships and also rigidity in behaviors, which would currently place him within the Autistic spectrum. The pt was diagnosed with Autistic spectrum disorder and the family was advised on behavior management. Upon internal review, autistic spectrum disorder and sleep apnea were considered to be other important medical events (OMIC). No further information is available.  All available medical records will be provided upon request.