Age: 1.2
Sex: M
Vaccine: MMR
Symptoms: Haematochezia, Hyperacusis, Injury, Myoclonus, Psychomotor hyperactivity
Clinical narrative: Follow-up information has been received from a foreign legal firm concerning a 14 month old male who on 1/5/94, was vaccinated with MMRII (batch 815000). It is alleged that the pt suffers from Myoclonic Epilepsy. On 1/13/94, the pt started experiencing "starring attacks". These attacks would last for 2 to 3 minutes. The pt's head would fall forward and his arms would jerk. Afterwards, he would sleep for around 3 hours. On 1/16/94, 3 days after the initial seizure, the pt was experiencing up to 8 seizures per day. Also noted on 1/16/94, the pt began to lose any speech he had developed prior to the vaccination. Within about 2 months, post vax, approx. 3/94, the pt's mother noted that he began to injure himself and started head banging behavior. He would hit his head repeatedly on the wall, hit the right-handed side of his head with his hand and bite his arms. In 9/94, the pt was noted to have lost his coordination and he developed an extreme dislike of being touched and an extreme sensitivity to noise. Also, at this time, his play became solitary, he lost his social skills and developed a fear of strangers. He also developed aggressive and spiteful behavior and lost his ability to concentrate and to maintain eye contact. His mother also noted that he became hyperactive. In approx. 6/94, (5 to 6 months, post vax) the pt began to suffer from constipation with occasional bloody stools. He would scream from the abdominal pain experienced while passing the bloody stools. The pt continues to suffer from constipation, however, the bloody stools have resolved. In 7/95, the pt was dx'd as having myoclonic epilepsy. Upon internal review, Myoclonic Epilepsy was considered an "Other Important Medical Event". No further information is available. Follow up information was received in the form of a consulation note dated 9/20/94. At the time of the visist, 9/8/94, the patient was 21 months old. His mother and maternal grandmother attended the session with him. A birth history was given by the mother who reported that ethe patient was born, breech presentation with forceps to the aftercoming head, at 37 weeks gestation, following a normal pregnancy. The patient had only mild jaundice which required no active treatment and was released to home at 1 week old. His birhtweight was 5 pounds, 9 ounces and he was bottle fed. The patient's developmental history was then discussed. The patient's mother had no concerns about the patient's early developmental milestones until about 13 months of age. At 5 months old the patient was sittin on his own, and was crawling, he walked at 13 months. At the time of this visit the patient's vocabulary consisted of about 6 words. There has been no advancement in his expressive speech other than the word "no". However, the patient does appear to understand everything. The patient tended to have a temper tantrums and frustration when he couldn't make himself understood. The patient would point at things, pull his mother by the hand or tug at her skirt when he would want something. The paitnet used his fingers to eat, but was able to use a spoon, and could also drink with a cup. The patient's vision was under review at the time of this consulation, however, there wer no concerns about his hearing at the time of the visit. The patient was able to walk up stairs one at time but comes down on his rear end. He also enjoyed climbing onto chairs so that he could look out of windows. A family history was also collected. The patient is an only child, however, the mother was expecting another child at the time of this visit. His parents are healthy and unrelated. The mother was 24 years old and the patients step father was 27 years old. The patient had contact with his natural father also. There was no familial history of epilepsy or learning difficulties. The mother had attended a normal mainstream school The family lived in a two bedroom ground floor apartment in which the patient had his own bedroom. The grandmother lived nearby and was very supportive as she was experienced in working with children with special needs. The patient had been very attached to his grandfather who died seven weeks prior to this visit. The patient tended to wander around the house looking for his grandfather. At about the age of 13 months the patient started having "vacant staring attacks". These attacks went on for about a month. The staring attacks were flooled by jerking movements of the head and upper limbs and the patient would fall to the floor. There was no loss of consciousness, and the attacks only lasted a few minutes. The attacks occurred about six to seven times per day but would happen while the patient was sleeping. The patient started to know when an attack was coming on and would sit down on the floor before it would occur. The patient was admitted to hospital to investigate these attacks. An electroencephalogram, computed tomography scan, organic acids test and chromosone tests were performed. A magnetic resonance imaging scan revealed delayed myelination. Anti-convulsant therapy which included a regimen of Lamotrigine 2.5mg daily and Sodium Valporate 80mg three times per day seems to have controlled the patient's seizures. The patient's mother and grandmother reported that the patient had been free from "fits" for seven weeks at the time of the visit. They also reported that he was not as sleepy and behaved more like a littl boy should. At the time of the consultation the patient was up to date with his immuniztions. The patient had shown no allergies and had been generally well, except for his seizures. On examination the patient weigh 11.25kg, above the 25 percentile; his height was 85cm, 50th percentile and his head circumference was 48 cms, which was also 50th percentile. The patient presented with no dysmorphic features. He related well with his mother and grandmother. The patient was righthanded and showed no undue clumsiness. He was cooperative but with a limited attention span that improved when in a one to one situation. The patient could use both hands equally well. The patient said no recognizable words but was able to carry out very simple commands. There was no evidence of squint on clinical testing and hearing responses using distraction tests were inconsistant. The patient's mother had no concerns about his hearing. The pediatrician's impression was the patient had a seizure disorder that was being well controlled at the time of the visit by using Sodium Valproate and Lamotrigine. He showed signs of mild global delay, functioning at a 15 month level(rather than 21 months) and with rather more expressive language delay. Formal testing of the patient's hearing was suggested as well as a speech therapy assessment. A playgroup was recommened, and another review was scheduled for six months later. It was thought that the patient may have an atypical form of Lennox-Gastaut Syndrome. However, the patient appeared to fit more into the pattern of benign Cryptogenic Myoclonic Epilepsy. Further follow up was received in the form of a consultation note dated 4/4/96, from the pediatrician. On this visit the patient was 3 years and 9 months old. The patient's grandmother brought him to the visit since the rest of the patient's family was home sick with the flu. The grandmother reported that the patient made progress, especially in his language development. The patient was saying more but stil lon a single word level, and only occasionally jointed two words together. The grandmother felt that the patient received much stimulus from his 16 month old baby brother who is developing normally and has very advanced language development. The patient's anticonvulsant treatment consisted of Epilim and Lamotrigine and the patient had been free from seizures for the last seven months. His behavior had improved also and was no longer considered to be a problem. The patient was attending his playgroup two mornings per week, but had recently started goign for a whole day one day a week to help prepare him for school in the coming October. The patient was toilet trained, able to feed himself and could eat with a spoon and fork. He was able to show understanding of the prepositions "in", and "on" and "under." The patient's speech was unclear and he communicated mainly using single words. The physical examination was essentially normaly, and both testes were palpable in the scrotum. It was concluded that the patient continued to show improvement in his development and his fits are well controlled using what was his current anticonvulsant treatment. The behavior difficulties he exhibited on the last visit were no longer a problem. However, the patient remained a child with mild global developmental delay and more sever expressive language delay. It was recommended that the patient continue to attend playgroup and Speech and Language Therapy. Further follow up information was received on 4/21/03 in the form of an Occupationaal Therapy Assessment Report dated 1/20/00. According to the report, the patient was first referred to the center in April 1998 by his Speech and Language Therapist due to concerns regarding his fine motor control. The patient was already known at the center as he had been attending Speech and Language Therapy since 1994. At the time of this assessment, the patient was 7 years old and his mother's main concerns were his reading skills, speech and concentration. The mother reported that the patient had developed normally up until around 14 months of age, until the time of his MMR (second generation) inoculation. She stated that one week after this injection, he began to have seizures (reportedly 8 or 9 per day) and he regressed in some areas of his development. She stated he needed to sleep long periods after each seizure and was missing opportunities for learning. At the time of the assessment, she reported that his seizures were well controlled, but that every 6-8 weeks he had an off day characterized by resorting to hurting himself and screaming. The Occupational therapy assessment report was based on observation of the patient in his classroom, assessment sessions, and further information provided by mother and teachers. The following tools were used to gain a picture of his developmental skills: Test of Visual Perceptual Skills (non-motor) Revised; Movement Assessment Battery for Children; Developmental Test of Visual Motor Integration; Informal Observations; and Handwriting Assessment. The patient presented as cooperative and motivated for the assessment.  The following findings were noted: Visual tracking - the patient found the tasks difficult and lost sight of the object. His poor concentration would have contributed to his difficulty with this task; Visual perception: his overall percentile rank was less than first percentile, which indicated a significant impairment. This could manifest as difficulties with reading, handwriting, spelling, copyiing and maths, as well as organizing oneself in the physical environment; Gross Motor Skills: the patient's scores placed him below the first percentile and informal observation indicated that his muscle tone was slightly low appearing to inpact on his postural stability, fine motor tasks, and the ability to accurately copy the movement and body positions of another; Fine Motor Skills: he scored below the fifth percentile which indicated a significant difficulty affecting both the quality and speed of his movements; Visual Motor Integratio: the patient scores placed him in the 6th percentile (equivalent to the performance of an average 5 year 2 month old) which indicated an impairment that would contribute to difficulties with handwriting, cutting with scissors, drawing and coloring; Self Help Skills: the patient was reportedly independent. In conclusioin, the therapist felt that the patient displayed some physical and visual motor difficulties, which were impacting on certian school related skills. The main difficulties were with visual tracking; visual perception (likely to have contributed to his handwriting and spelling difficulties); delayed ball skills; motor planning; fine motor dexterity (including pencil grasp); visual motor integration 9impacting on a number of aspects of handwriting skills); and an inability to tie shoelaces independently. Recommendations for optimizing the patient's classroom learning along with activities and suggestions for promoting the patient's skills in these areas wree made (information not available).  Follow up information received on 4/21/03 reported the patient's immunization history consisted of Pertussis, diphtheria, tetanus, polio Haemophilus influenza type B vaccine givien on 1/26/93; 2/24/93 and 3/24/93. PSB was given on 6/19/96. Upon internal review, mild global developmental delay and severe expressive language disorder were considered other important medical events (OMIC). No further information is available. This is a consolidation of two reports concerning the same patient. A copy of the patient's complete medical record is available upon request.