Age: 40.0
Sex: F
Vaccine: MMR
Symptoms: Headache, Hearing impaired, Neurological symptom, Otosclerosis
Clinical narrative: Information has been received from a physician concerning a female in her 40's with a history of rash with docycyline who on 8/12/03 was vaccinated with a dose of MMR (lot # 640788/1180M), and on 9/16/03 was vaccinated with another dose of MMR (lot # 645267/0101N). On 9/30/03, the patient was seen in the office for a headache that started a few days before the visit. On 10/2/03, the patient was seen by an ENT specialist for loss of hearing, right profound neuro loss and left mild neuro loss. A hearing test and MRI were performed. The patient was diagnosed with loss of hearing and otosclerosis. The patient was treated with valacyclovir, ranitidine HCl, pseudoephedrine, guaifenesin, fexofenadine HCl, triamcinolone acetonide, paromomycin SO4, and calcium. At the time of this report, the patient's condition had not improved. Additional information has been received from the physician who reported that the pt did not have any significant medical history, and that she had normal hearing prior to vaccination. The physician indicated that the pt was vaccinated because of school requirements. The pt did not want to have titers drawn, so the pt received the vaccination. There had been no improvement in the pt.  Loss of hearing and otosclerosis were considered to be disabling. Additional information has been requested. Follow up on 06/08/04 states: "Follow up information has been received from a physician via medical records. The 45 year old female pt with a history of tonsillectomy (1969) and melanoma back (1995), a family history positive for hearing loss (negative for dizziness and tinnitus) who smoked half a pack per day presented to the physician with hearing loss. The symptoms began around the last week of 09/03. When she awoke in the morning, she found there was a feeling that the room was moving and she had a pressure feeling in the right ear.  When she was in motion as with transportation it precipitated nausea and vomiting. She was seen and examined and treated for a sinus infection. When there was no change in her symptoms for about 2 days, she was subsequently seen and evaluated by an otolaryngologist. There was found to have a significant hearing loss. She was treated with two weeks of prednisone and Valtrex. The nausea disappeared after about 4 days and the problem with the balance disappeared after about 3 weeks. She was subjectively aware of some return of hearing but not to the previous level. There was no problem with the hearing in the left ear. The aural fullness in the right ear continued. Superimposed on this periodically was a pain in the right ear. She was aware of a constant tinnitus in the right ear that had been present from the onset. It sounded like the noise coming from a fluorescent light fixture. Superimposed upon this periodically for brief periods were other sounds in that ear. There was no tinnitus or aural fullness in the left ear. On review of symptoms, there was no fever, weight loss or gain, fatigue, depression, nervousness, or trouble sleeping. She had headaches, beginning in the right eye to neck and shoulders for 5 years, once a month, some related to menstrual cycle. Nothing helped but were less with recent diet change. No head injury was reported. Review of eyes, nose and throat, mouth, neck, urinary, endocrine, heart, lungs, digestive, liver, back, arms and legs, neurologic, bleeding, reproductive, and gynecolgic systems revealed no injuries or abnormalities. The pt was currently taking Synthroid. Her diet was under nutritional guidance. A complete neurologic specialy examination was undertaken. General appearance of pt revealed normal developement, normal nutrition and body habitus, no visible deformities, and good attention to grooming. The pt had good ability to communicate and mood and affect was appropriate. External inspection of the ears and nose with attention to the general apperance and presence of any lesions, scars, masses or inflammation detected no abnormalities. Examination of the external auditory canals for the presence of cerumen, inflammation, lesions or evidence for cholesteatoma detected no abnormality. Examination of the tympanic membranes for appearance, general mobility, presence of lesions, perforations or other abnormalities detected no abnormalities. Assessment of hearing with tuning forks revealed: Weber-to the left, Rinne-positive AU, AD <<AS 0,5kHz, AD<<AS 2.0kHz, and AD<<AS 4,0kHz. Clinical speech reception thresholds with little difficulty. Test ocular motility included primary gaze alignment normal.  No nystagmus, normal vengence. Tests of 2,3,4,6,7,11,12 cranial nerves performed normally. Tests of trigeminal nerve function revealed tough reduced right all three divisions, pain reduced left second division, corneal sensation reduced right. The cerebellar function (test of coordination) was performed normally. The regular Romberg was performed normally, the sharpened tandem Romber was performed with difficulty-mild with the right foot forward and mild to moderate of the left foot forward. Nuchal tenderness was present bilaterally more on the left initially-with repeat examination less spasm and tenderness. Audiology exams were performed from 10/02/03, 10/17/03, 12/11/03, 01/12/03.  The initial audiology showed a severe to profound hearing loss in the right ear with a mild low tone decline in the left ear, a mild to moderate decline in the higher tones in the ear with a mild conductive component. Audiology performed on 10/17/03 showed an improvement in the hearing in both ears although performed in a different facility. The audiology performed in December and January showed some further improvement in the hearing in the right ear and in the left ear with a conductive component as of Jan 04.  While there was no speech discrimination initially, there was some speech discrimination ranging from numeral 8% to 12% in the right ear. The left ear was in the normal range. With the exeption of the audiology performed on 10/17/03, the other three tests showed contralateral reflexes present when the phone was in the right ear indicating a cochlear site for the hearing loss. The reflexes were elevated contralaterally in the left ear and negative for abnormality with contrast. Lab evaluations complete blood count normal, calcium 9.5, TSH 0.92, 1.36, ANA negative, cholesterol 247, triglycerides 121, and LDL cholesterol 166. The impression was sudden hearing loss, sensorineural hearing loss, speech discrimination impaired, tinnitus, unspecified aural fullness, and dizziness, vertigo and disequilibrium. The pt was subsequently seen for a follow up consultation. It was noted that in August 2003, the pt underwent immunization for MMR. An audiology exam revealed flat right sensorineural hearing loss-slightly improved over the test performed on 01/14.  Left ear showed a mild flat sensorineural loss through 1kHz with a mild to moderate decline through 8kHz. Moderate threshold right ear with impaired speech discrimination was slightly better than the last test performed (right ear 60 dB SRT 16% SDS at 90dB, left ear 20 dB SRT 100% SDS at 60dB).  Tympanometry was normal for both ears. Acoustic stapedial reflexes-cochlear site right ear, early absent contralateral left ear, could not test right ear contralateral, equivocal ipsilateral right ear, positive ipsilateral left ear. Lab evaluations revealed glucose tolerance test was exaggerated to hypoglycemic-not normal for inner ear, and insulin tolerance test was normal. A thin section CT of the temporal bones revealed symmetrical internal auditory canals, basal turns of the cochlea-mixed sclerotic/spongiotic plaque, sclerotic, moderate anterior and mild posterior right ear, mild anterior and posterior left ear, pericochlear lucency-fan area medial to sclerotic plaque, and foot plate-thickened mild right ear,normal left ear consistent with inner ear otosclerosis.  The assesment was cochlear-sensorineural hearing loss, speech discrimination impaired, aural tinnitus, aural fullness, otosclerosis, hypoglycemia, and hypercholesterolemia. The audiology revealed a sensorineural hearing loss of cochlear or sensory site as opposed to nerve or neural site. The portion of the hearing test devoted to understanding the spoken word showed impairment of the ability to discriminate the meanin of a one syllable word. The findings including the imaging of the temporal bones revealed otosclerosis/otospongiosis as the cause of the symptoms. This was a demineraliztion of the capsule of the bone around the inner ears. The case was unknown. Byproducts of the breakdown of bone and cytokines seeped into the inner ear fluids to interfere with inner ear function leading to the inner ear symptoms. The glucose tolerance test revealed hypoglycemia sufficient to interfere with the normal function of the inner ear. The lipid panel revealed an elevation in the serum lipids sufficient to interfere with the normal function of the inner ear. Treatment included a diet modified hypglycemic and low in fat and therapy with risdronate sodium (Actonel) 30mg twice weekly, calcium supplement with vitamin D, and monocal 1 daily. Cochlear sensorinerual loss of hearing and otosclerosis were considered to be disabling. No additional information is expected. A copy of the pt's medical records have been attached as further documentation of the pt's experience."