Age: 1.08
Sex: M
Vaccine: MMR
Symptoms: Abnormal behaviour, Anorexia, Autism, Diarrhoea, Disturbance in attention
Clinical narrative: On the evening of the day of vaccination, the patient developed a temperature and became irritable and difficult to settle. The temperature resolved the next day but the patient remained groggy for approximately 2 to 3 days following the vaccination. On 08/19/93, the day following the vaccination, the patient developed diarrhea which lasted for 2 days. One week following the vaccination, on approximately 08/25/93 the patient developed a rash behind both ears which faded in the next few weeks, but did not disappear completely. It was noted that the patient's health and behavior deteriorated gradually after the MMR vaccination. With in a few weeks of the injection, the patient's personality began to change and he became withdrawn. The rash, which developed behind his ears following the MMR vaccination faded but did not disappear and his eyelids became very red in color. In addition, he began to develop night sweats. By the beginning of November of 1993, the patient had become very irritable and "grisly" (Irritable was considered to be an incidental finding). He also developed a very pale. almost white complexion, lost of appetite and would frequently suffer from upset stomachs (Pallor and loss of appetite were considered to be incidental findings). By this time, the patient lost interest in social interaction and play and developed an increased need for sleep, often sleeping for long periods of time. He became fussy with foods and would only eat certain foods and would no longer eat foods he had previously enjoyed. This fussiness has continued. He no longer seemed to cry or respond to painful stimuli. At this time, he began walking on his tip toes which he continued to do and began dribbling and putting various objects into his mouth. By Christmas 1993, the patient's behavior had become increasingly disruptive. He had tantrums and disliked leaving home environment. In addition, he had developed an obsession with a toy and had lost his concentration and would no longer respond to others when they attempted to communicate with him. His thirst patterns also increased at this time and this was accompanied by a deterioration in his speech as he seemed to loose words he had used prior to the MMR vaccination (increased thirst pattern was considered to be an incidental finding). Shortly after these symptoms developed, the patient began to suffer diarrhea and the color of his motions occasionally became cream in color. On 07/25/95, the patient was noted to have poor concentration, little or no eye contact and was very uncooperative. The patient was diagnosed to have Autistic Spectrum Disorder in January 1996. It was noted that the patient had no relevant pre-vaccination conditions or relevant family medical history. The patient did not receive any other vaccinations containing MMR and did not have measles, mumps, or rubella infection. The patient's Autistic Spectrum Disorder was considered to be an other important medical event. No further info was available. Additional info from the pt's medical records noted tha tthe pt was seen on 11/8/95 by a pediatrician. The pediatrician noted that the pt was born at term by spontaneous vertex delivery weighing arund 7 lbs. There were no neonatal problems. The pt's mother recalled that the pt has normal milestones, although she couldn't recall exact dates. There were no concerns about sitting, walking or talking. the pt has one older sister. The pt's father required soem extra help at school for reading difficulties but there was no other family history of any speech/language or behavior problems. The pt had no serious illness of note and his general health was good. He slept well at night. His appetite was variable; however, there wasn't a particular type of food that the pt refused to eat. The pt's mother had taken him away from other playgroups previously; however, he had started at a private nursery where he has a 1:1 helper. The pt's mother was delighted because it was noted that his behavior was very good there and he had started to play with other children. The pt's mother was very pleased because the last time he was at the nursery he had wanted to know all the other children's names and had gone up to them and stroked their hair. He was also attending speech therapy on a 1:1 basis weekly. The pediatrician was unable to examine the pt because he became very upset when this was attempted. It was noted that the pt's behavior was better than it was previously, although he still enjoys throwing things around the room, he would look at them for a bit and then throw them. It was noted that the pt walked on tip-toes and his mother stated he tended to do this more at home when he was excited. He would be fairly happy when doing what he wanted to do but screams uncontrollably when one tried to direct his behavior. It was noted that it was only possible to do something with the pt on his own terms and he really didn't like it if one tried to get him to do some task. The pediatrician noted that the pt may lie on the autistic continuum in the aspects of his behavior that was observed in the clinic. It was suggested that the pt have some routine blood tests. Info from the pt's medical record on 09/10/96, noted that the pt was diagnosed as having autism. It was ntoed that the pt's mother was quite concerned after having spoken to other people of autistic children as they commented that he had not had testing for allergies particularly as he was an asthmatic and had eczema. He also had a cousin who had a severe nut allergy. It was recommended tha tthe pt be seen and advised as to whether or not he had a nut allergy. The pt had "only very mild asthma" which was controlled with albuterol as needed. It was noted that the pt's past medical history was significant for : on 02/27/93, the pt had pharyngitis that was treated with Calpol, on 03/09/93, the pt had an upper respiratory infection and on 04/17/93, it was ntoed that the pt's elimination was "not alright." On 11/15/93, the pt had bilateral tear duct blocked and a rash on his face which was noted to be worsening. On 04/06/1994, the pt had upper respiratory infection. On 07/26/94, the pt's mother was concerned that his tonsils were large and the right was greater than the left. It was determined that the pt had normal large not-infected tnsils. On 09/08/94, it was noted that the pt had a fever at night. On 12/11/95 and 12/18/95, the pt was seen by a clinical psychologist who noted that the pt was born by normal delivery at term and there were no neonatal problems or significant illnesses. There were no hearing concerns. Theh pt was seen on 12/06/95 by an orthoptist and was ntoed to have adequate functional vision, but it was not possible to check him for refractive errors. It was ntoe dtha thte pt has an olde sister who had no concerns. It was reported that the pt's developemnt was normal until around 2 years of age when his behavior became extremely difficullt. His speech had platesued at this time. It was noted that his behavior was "now improving," there was less running off and the pt was showing more interest and tolerance of other people. He still continued to be very active and like to play on his own, but would accept his mother playing engaging in play. The normal family outings were resumed, however the pt's behavior remained unpredictable. The pt was tried at two playgroups and a private nursery; however, he was unable to cope. He was now settled in his present nursery and was noted to join in for story, sat with the other children, palyed alongisde, wanted to know their names and would stroke their heads. Apart excellent memory. The pt was seen over two occasions, once iwth his mother and once with his father. The pt was more cooperative with his father. TWo non-verbal subscales and interactional play formed the basis for these sessions. Info from the video of father/child play was also used. It was noted that speech and language have shown a marked improvement over the last six months. The pt now had a wide vocabulary of single words and had linked speech. He could verbally request with mainly single words. His speech seemed ot be rather stereotyepd an dlacked flexibility. Occasionally his speech was inappropriate. He copied words readily and echoed where he did not undersntad. he found questions difficult to respond to, except of "what's that," he was very comfortable with naming activities for pictures and colors. Sometimes his speech was unclear. He was starting to use personal pronouns in speech. His social communicaiton was inconsistent. He could show good interactional skills using appropriate gaze switching and shared pointing combined with speech. At othe rtimes the pt's eye contact was poor, and he would ignore interactions from others. He liked to be in control and would await reactions to provocative behavior. He did respond to clear firm directions, particularly from his father. He was seen to respond to praise. He generally showed low tolerance of frustration. He found it difficult to watch demonstration of activity. There as some very mild lining up in play, and some mild perseveration of play was also noted.