Age: 40.0
Sex: M
Vaccine: LYME
Symptoms: Sensation of heaviness, Walking aid user
Clinical narrative: This case was reported by a lawyer and described the occurrence of joint stiffness in a male subject of unspecified age who was vaccinated with Lymerix (GlaxoSmithKline). 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 joint stiffness, flu-like symptoms, muscle stiffness, fatigue, headache, memory loss, rheumatological symptoms, cognitive impairment, 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 31 October 2007 via medical records, which revealed that the subject was in his forties. Dates of LYMErix vaccination were not provided, although physician's notes dated 13 June 2005 and 17 October 2005 indicated that the subject had reportedly received Lyme vaccine in the past. Medical history (prior to 1999), included mild dysesthetic pain, bilateral lower extremity muscle tightness, stiffness/inflexibility and "mild" spasticity of lower extremities, evidence of early spinal cord compression/spinal spondylosis (1996), and cervical disc injury corrected by surgery (cervical discectomy in July 1997). In approximately 1999, the subject developed increasing weakness in his left leg, and described increasing weakness during the course of each day and "eventually" dragging his toe. In April 2000, he was diagnosed with lumbar (L5) radiculopathy. On 17 May 2000, he was evaluated for progressively increasing leg pain, described as diffuse pain in the lumbar area with radiation to the left leg and subjective weakness and numbness. In May 2000, be underwent an L4 to L5 microdiscetomy due to worsening stiffness of the bilateral legs. He had used a cane prior to surgery, and experienced subsequent improvement for "several weeks", followed by recurrence of symptoms. The subject was evaluated on 26 October 2000 with a "several year history" of left lower extremity weakness with bilateral stiffness. At the time of evaluation he did not require use of a cane. He returned for follow up through a least 01 February 2001, with complaitns including persistent lower extremity weakness (left greater than right), bilateral lower leg fatigue, intermittent paresthesias, low back pain, and feelings of leg heaviness. Diagnostic findings included disc hernations and degenerative changes that were "unchanged from previous evaluation". Treatment included Celebrex. He also received caudal epidural injections for treatment of chronic low back pain/lumbar radiculopathy on 27 November 2000, 08 January 2001, and 20 January 201, with Levaquin prescribed for prophylaxis. Following epidural injections he experienced a "significant" reduction in symptoms with improvement for two to three weeks, followed by return of symptoms. Following use of an inversion table in approximately January 2001, he developed lower back spasms, and presented to the emergency room where Valium was prescribed. In approximately April 2001, the subject developed "new" right leg weakness and numbness. Diagnostic tests revealed discogenic degenerative changes and mild degenerative joint disease of the lumbar spine, and mild throacic dextroscoliosis. The subject was followed between May 2004 through as recently as 18 June 2007 for a chief complaint of multiple sclerosis (MS). The specific date of MS diagnosis was not provided. Symptoms reported during the course of evaluation included spastic gait requiring increaseing use of a cane. He reported that he did not use antispasticity medication on a regular basis due to associated weakness. The subject described the tendency of his left leg to "lock up at the knee", which resulted in falls if on uneven ground. Medications included Zanaflex, Neurontin and Copaxone. He also reported that marijauna was helpful for nocturnal pain and leg cramps, jerking, and burning pain. In February 2007, diagnostic testing revealed multiple periventricular ischemic areas of plaque in the brain, and multiple areas of demyelination of the cervical spine. Clinical impression on examination on 16 March 2007 was "relapsing-remitting multiple sclerosis" with symptoms suggestive of early to secondary progressive features. He was placed on a Cytoxan-steroid protocol for six months. Other medications at that time included Celexa. Upon follow up on 18 June 2007, the subject complained of feeling "more stiff and limited" while noting concomitant physician and emotional stress. A past medical history of cervical stenosis and lumbar spine disease was also reported (dates of onset not provided). He remained on Copaxone, Neurontin, and Zanaflex. This report was assessed to be medically significant based upon follow-up information. Examination resulted in an impression of left leg muscle weakness and decreased sensation in the L5 dermatome, and bilateral lower extremities muscle stiffness. The subject developed depressive symptoms due to surgery. This was considered to be an incidental finding upon medical record review.