Age: 10.0
Sex: F
Vaccine: HPV4
Symptoms: Pain, Pruritus, Strabismus, Venogram normal, Vision blurred
Clinical narrative: Information has been received from health professional concerning an 11 year old female with nearsightedness and drug allergies to ZITROMAX, sulfamethoxazole, plus BACTRIM, and sulfa, who on 06-JUN-2007, 08-AUG-2007 and 08-NOV-2007 was vaccinated into the right arm with the first, second and third doses of GARDASIL (Lot# first dose 657737/0522U, second dose lot#658222/0927U and third dose lot#659435/1265U). On 15-SEP-2007 the patient experienced headaches and was diagnosed with pseudotumor cerebri by neurologist and neuro-ophthalmologist. On 10-OCT_2007 she was seen by a neuro-ophthalmologist who felt that she had mild myopia on the right eye, intermittent exotropia and mild elevation of the optic nerves nasally, right side worse than left. Venous pulsations were not noted. The physician indicated that she needed studies to rule out an intracranial cause of the elevation of her optic nerves and it was suspected that she might most likely have pseudotumor cerebral. On 15-OCT-2007 she had a magnetic resonance venography (MRV) which was also normal. On 19-October-2007 the patient saw a neurologist who reported tha the patient is an 11-year-old young lady sent for evaluation of probable pseudotumor cerebri (PTC). Her problems began about 1 month ago (mid September), when she had suden onset of horizontal double vision and she noted that her eyes were turning in. She stated the two images are side-by-side. She was seen by her family doctor and then and ophthalmologist. A few days later she developed headaches.  She describes her headaches as fluctuating, sharp pain at the top and back of her head. She also experienced pain in her neck.  The pain was more severe in the morning and at about noon each day. When the pain gets worse, her eyes get a bit blurry and hurt. Her vision might also darken slightly. She sometimes felt somewhat unsteady and weak with a headache. She was taking over-the-counter medication without improvement of the heacaches. At times she felt some achiness of her body. She injured her wrist in March 2007. She did not tear the ligament but did strain them.  The physician she saw was concerned that she might have juvenile arthritis. She was started her on MOBIC, but her mother discontinued it because the patient was experiencing itching. The itching symptoms have not improved off of the MOBIC. They plan to start some physical therapy. She was born at term, birth weight was 7 pounds, 10 ounces and mother was 30 years old. This was mother's second pregnancy and delivery. Pregnancy, labor, and delivery were uncomplicated. She was not required any overnight hospitalizations. Development has been normal in both motor and cognitive skills. She was in the sixth grade and was a good student. She began wearing glasses one year ago. She was felt to be nearsighted. She has not experienced any head injurys or concussions. She enjoys cheerleading. Family history includes her mother and several of her siblings, maternal grandmother and paternal grandmother all have a history of migraines. Maternal grandmother and maternal great-grandmother died from rupture cerebral aneurysms. Mother also has a hisory of some crowding of her optic nerves (with a normal MRI of the brain). On physical exam, her head is normal in shape and size. Blood pressure was 112/64 mmHg, pulse was 70. Facial features were normal in appearance. Mouth and throat were clear. Neck is supple. Lungs were clear. Heart had a regular rate and rhythm. Abdomen was benign. skin was clear. Extremities have no clubbing, cyanosis, or edema. Capillary refill was less than 2 seconds. Neurologic examinations revealed the patient to be awake, alert, and coherent. Memory was normal for recent and remote events. Affect was appropriate. She reports a headache of three out of five in intensity and has some light and sound sensitivity. Cranial nerves: pupils are equal round and reactive. Fundoscopic examinations reveals slight blurring of the nasal borders of both optic nerves and the lack of spontaneous venous pulsations. Eye movements were normal in that there is limited abduction of each eye. There was a worsening of her double vision as she looked laterally. Visual acuity was 20/20 bilaterally using a Rosenabum card. Visual fields appear full to confrontation. There was no nystagmus.  Facial movements are symmetric. Palate rises in the midline. Voice tone is normal. Shoulder shrug is strong. tongue is midline without fasciculations. Motor examination: muscle tone, bulk and strength are noted in all muscle groups. Deep tendon reflexes: two plus bilaterally in both upper and lower extremities. There was no ankle clonus. Plantar responses are downgoing. Cerebellar examination: nose to finger testing was normal. There was no ataxia, or dysmetria. Gait and tandem walking were normal. Impression was that the patient was 11-year-old girl with what was believed to be pseudotumor cerebri. She had elevation of her optic nerves and blurring of the nasal borders, a lack of spontaneous venous pulsations, double vision with an apparent bilateral sizth cranial nerve palsy and intractable headache occurring at the top and back of her head. Her MRI of the brain, MRI of the orbits and MRV are all normal, fortunately. Results of lumbar puncture (LP) under anesthesia performed today to reasure the opening pressure (OP) were 34 centimeters (cm) of water and the closing pressure was 15 cm of water after we removed approximately 14 cc of clear cerebrospinal fluid (CSF). The CSF studies were normal. Following the LP she had some positional headache (probably a post LP low-pressure headache) that resolved in a few days with rest and hydration with caffeinated beverages. We will then most likely place her on acetazolamide (MSD). She certainly was a set up  for pseudotumor given her approaching adolescence and puberty, her being slightly overweight, and her tremendous growth in the last year. Her mother reports that she had grown perhaps 4 or 5 inches in the last few months. On 22-OCT-2007  she saw an orthopedist with complaints of left wrist pain. She was seen by a rheumatologist who did not feel that she had rheumatoid arthritis, according to her mother. The feeling was that it may be an over use type syndrome. She gave her a prescription for some ati-inflamatories but she's not able to take those. She had some cerebral spinal fluid drained from her back as she had elevated cerebral spinal pressure. she is now feeling better since that has occurred. she was still using the brace and she had not yet done any kind of tumbling. On exam her left wrist was tender dorsally. She had negative Finkestein maneuver. She was tender over the second extensor compartment. Grip strength feels equal bilaterally. She could symmetrically flex and extend both wrists. She can pronate and supinate both forearms. She had negative Tinel over her carpal tunnel and negative Tinel over Guyon's canal. she was nontender over the distal ulna. She had negative ulnar grind. Media and Lateral collateral ligaments were stable to stress at her left thumb metacarpal phalangeal joint. Assessment revealed left wrist pain and tendosynovitis. Agree to follow the rheumathologist's recommendation and to take the anti-inflamatory meloxicam (MOBIC). She should finish out the prescription. Once she was done with cheerleading, it was suggested that she gets her into some therapy to do some modalities and treatments to hopefully help the persistent symptoms that she was having. It was also recommended that she keep her body weight off the hand and not do any kind of tumbling. Follow up in 6 to 8 weeks to see how the wrist was feeling, then consider discharge if appropriate. Apparently she was not allowed to tumble yet either because of her elevated spinal fluid. The patient and her mother are in agreement with the treatment outlined.  On 24-OCT-2007 she was seen by the neuro-ophtahalmologist. She unfortunately has a pseudo-tumor cerebri with opening pressure in teh 300range according to the patient;' mother who was an extremely reliable historian and whom has known the physician personally for lot of years. The patient was now headache free and we see she has spontaneous venous pulsations of the optic nerves which were not seen on the last visit. MRI revealed changes in the mastoid consistent with possible mastoiditis and was deferred to a otolaryngologist. From a purely ophthalmic perspective the plan was to see her back in one month to six weeks for a repeat visual field and re-evaluation of the optic nerve.  On 01-NOV-2007 at a follow up visit the neurologist she stated that post LP she developed some headache and it was  felt that she had good venous pulsations and change in he papilledema. There are other symptoms. she does not have double vision. She was currently taking acetazolamide (MSD) 250 mg BID for the PTC. Physical exan was within normal limits. Blood pressure was 112/62, and pulse was 70. She reported a headache of "seven" out of five in intensity and had some light sensitivity. she did not appear to be uncomfortable. Pupils were equal round and reactive. Fundoscopic exam revealed more sharp nasal borders of both optic nerves and I can see spontaneous venous pulsations today. Eye movements were normal today without limitations of abduction of each eye. Visual acuity is 20/20 bilaterally using a Rosenbaum card. Visual fields appeared full to confrontation. There was no nystagmus. Facial movements were symmetric. Palate rises in the midline. Voice tone was normal. Shoulder shrug is strong. Tongue was midline without fasciculations. Motor exam revealed muscle tone, bulx and strength were normal in all muscle groups.  Deep tendons reflexes were two plus bilaterally in both  upper and lower extremities.  There is no ankle clonus. Plantar responses are downgoing. Cerebellar exam revealed nose to finger testing normal. There was no ataxia or dysmetria. Gait and tandem walking were normal. Plan was to continue her on the acetazolamide (MSD) 250 mg BID and follow up i two weeks. It was felt that her intracranial pressure is likely normal at this time. She had improved nasal borders of the optic discs and spontaneous venous pulsations. Her double vision had resolved. I was unlikely that she is now experiencing a low-pressure headache, given the fact that it was no positional. By the end of  the office visit, she was happier and appeared even more comfortable. The physician was not sure if she was perhaps experiencing some anxiety concerning her medical condition, causing her some headache.  On 07-NOV-2007 the patient returned to her neuro-ophalmologist stating that she was doing a lot better with the strict bedrest therapy that was provided to her. It was thought that she developed a spinal leak when she was doing cheerleading and so certainly we agree that cheerleading should be stopped until the neurologist releases her to return to cheerleading.  The optic nerves look better than ever and they are close to being flat. Plan is to perform anti-thyroid antibodies, although it is assumed that the pseudotumor was associated with growth spurt, but the patient did have a fullness about the neck, and thyroid disease can be associated with PTC.  On 16-Nov-2007, she was doing marvelously well. She had not been having headaches. She saw her neuro-ophthalmologist earlier that week who felt she was doing very well and that her optic discs were practically flat. He will next see her in January with visual fields at that time. She remains on acetazolamide (MSD) 250 mg BID and tolerates it well. Physical exam was within normal limits. Blood pressure was 110/62 and pulse was 70. Neurologic exam revealed that she was awake, alert, and oriented.  Cognitive abilities were age appropriate. Attention was normal. Speech was clear and coherent. Memory was normal for recent and remote events. Affect was appropriate. She had no headache today.  Pupils are equal, round, and reactive. Fundoscopic exam revealed mor sharp nasal borders of both optic nerves and spontaneous venous pulsations could be seen. Eye movements were normal without limitation of abduction of each eye. Visula acuity was 20/20 bilaterally using a Rosenbaum card. Visual fields appeared full to confrontation. There was no nystagmus. Facial movements are symmetric. Palate rises in the midline. Voice tone was normal. Shoulder shrug is strong. Tongue was midline without fasciculations. Motor exam revealed muscle tone, bulk and strength were normal in all muscle groups. Deep tendons reflexes were two plus bilaterally in both upper and lower extremities. There was no ankle clonus. Plantar responses were downgoing. Cerebellar exam revealed nose to finger testing was normal. There was no ataxia, or dysmetria. Gait was normal. She was certainly set up for pseudotumor, given her approaching adolescence, puberty, being slightly overweight and her tremendous growth in the last year. The plan was to continue her on the acetazolamide (MSD) 250 mg BID and I will see her in January 2008. She was encouraged to increase her level of activity and eat sensibly. On 19-DEC-2007 she had a follow up visit with the orthopedist. She had been dealing with left wrist pain that waxes and wanes. she had some therapy. She was taking the acetazolamide (MSD) and unfortunately was not able to take any kind of anti-inflammatory medication. She had complaints of spontaneous left ankle pain. She denied falls, accidents, or traumatic injuries that she could recall. She was accompanied by her mother. On exam she could symmetrically flex and extend both wrists, pronate and supinate both forearms, flex and extend both elbows. her grip is equal bilaterally when squeezing my fingers, She was tender along the dorsum of the left wrist. There is no increased pain resisting wrist extension. She has a negative Tinel's over the carpal tunnel. On her left ankle she is tender doing the joint line. She was tender along the medial and lateral malleoli. She was tender along the anterior tibialis tendon. She could actively flex and extend the ankle joint. She had a palpable dorsalis pedal pulse. She could walk without a limp. Assessment and plan included left wrist pain and tenosynovitis, left ankle pain and synovitis. Unfortunately, with the acetazolanide (MDS) for elevated cerebral spinal fluid she needs to stay off of anti-inflammatories. I would think with more therapy and some anti-inflammatory medication this could potentially help her. She will try to maintain an active level that is tolerable for her. I would defer to the neurologist for any kind of contact sports or any impact sports. If she can take medication, I would consider getting her back on meloxicam (MOBIC). Her mom will call and let us know. If that is allowable. Otherwise follow up is planned for six to eight weeks. Both the patient and her mom are in agreement.15-JAN-2008 ophthalmology exam revealed healthy optic nerves and normal visual field test on the right side. On the left site there was some mild central defect probably related to artifactual because the retina is health. Plan is to follow up in four months. On 18-JAN-2008 the patient had a follow up  visit with the neurologist. she was doing very well. Her acetazolamide (MSD) was increased to 250 mg TID when she was complaining of more headaches, but was not having any visual changes. Since that time, she had not been having any major headaches at all. The patient states that her papilledema was nearly resolved and her visual fields were also improving. Physical exam was within normal limits. Blood pressure was 104/52 and pulse was 70. This patient was with resolving pseudotumor cerebri. Plan was to continue on the acetazolamide (MSD) 250 mg TID and to follow up in three months. If all was going well at that time, consideration would be given to weaning the acetazolamide (MSD). She was encouraged to increase her level of activity and eat sensibly. On 01-JUN-2008 the patient recovered from headaches and pseudotumor cerebri.  No further information is available.