Sex: F
Vaccine: LYME
Symptoms: Activities of daily living impaired, Arthralgia, Back pain, Balance disorder, Condition aggravated
Clinical narrative: This case was reported by a lawyer via a statement of injuries and described the occurrence of neck pain in a female 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 neck pain, back pain, stiff back, joint pain (knee, elbow, shoulder, and right ankle), scapula pain, thigh pain, severe headaches including migraines, leg heaviness, loss of balance, fatigue, "mottling in her eyes", and numbness/tingling in her toes, legs, back, arms, face, and fingers. The statement of injuries further alleged that the events "negatively impacted on her activities of daily living and enjoyment of life". At the time of reporting the outcome of the events were was unspecified. Follow-up information was received on 27 July 2009 via medical records. The subject was evaluated on 27 November 2001 for her headaches. She reportedly had a history of headaches for many years. Following exam, it was believed that the subject was suffering from either tension headaches versus migraines. She described a constant pulling feeling in the back of her head suggestive of a tension headache. However, migraine headaches can sometimes be associated with constant occipital pain. She has a family history of migraine. Her exam was unremarkable. The subject was seen again for headaches on 29 January 2002. It was remarked that it was not clear whether the subject suffered from tension headache versus atypical migraine. She was placed on Amitriptyline. The subject was evaluated for headache through 28 January 2003 and continued to do well on Amitriptyline. On 20 May 2003, it was reported that the subject was experiencing frequent headaches. The headaches were described as migraines. She was taking Amitriptyline, ACTONEL and ELAVIL. She was switched to TOPAMAX at this visit. In follow-up on 26 August 2003, it was reported that headaches were better and resolved after she stopped drinking coffee. At this visit, the subject reported right shoulder pain and pain at the tip of the right shoulder blade. She received chiropractic treatment and shortly afterwards started to experience numbness in the right second toe and occasional numbness in the left foot. Once she reported numbness in her fingertips bilaterally, but it resolved. Impression was believed to be cervical spondylosis. She was referred for physical therapy. The subject's second problem was numbness in the toes which was associated with decreased vibratory sensation on examination. This was suggestive of possible early polyneuropathy; the etiology was not clear. Additional testing was suggested. On 13 October 2003, the subject was seen in follow-up with new complaints of low back pain and spasms in the lower back. She was still having symptoms in both lower extremities. She had tightness in the calf muscles bilaterally and numbness in the toes. The