Age: 44.0
Sex: M
Vaccine: FLU3
Symptoms: Diplopia, Encephalitis, Headache, Malaise, Neck pain
Clinical narrative: It was reported by the pt that he, a 44 year old male, received a Fluzone '01-'02 vaccination on 10/26/01. The pt developed double vision on 10/28/01; the double vision is still persisting. Pt also experienced tingling in hands and feet, and a general feeling of malaise. He complained of pain in his neck and continued pressure behind his eyes and has a splitting headache. The pt has seen a neurologist, internal medical doctor and an Ophthamologist. He was dx'd by the Ophthamologist as having post viral encephalitis triggered by the flu vaccination. The pt did state that no spinal tap was performed as of yet. From follow up correspondence received on 12/14/01 additional pt, vaccine, responsible physician, vaccine administrator and laboratory data was provided. From follow up correspondence received on 12/14/01 additional patient, vaccine, responsible physician, vaccine administrator and laboratory data was provided. From follow up correspondence received on 2/11/02 the following information was provided from teh physicians notes dated 1/14/02. The patient returns reporting overall he feels much better. He feels his ptosis is completely resolved. He feels wach eye is moving much better at this time but he questions whether his eyes are crossing inwards more. The patient has previous opthalmic history with regards to his spectacles. When examining his refraction he has a marked optical diffrence between his two eyes with his right eye being much more hyperopic than his left. He is experiencing minimal if any diplopia at this time. The patient is showing a marked improvement in his overall gaze paresis. At present he has relatively full duction in both eyes. His ptosis has also improved. However, he is demonstrating an increase in his objective strabismus angle with partial sensory suppression of his right eye. The fact that this tribasic angle is overall increased at this point is not necessarily concerning. In particular, he had very limited duction in all fields of gaze before which might potentially hide his true angle of strabismus secondary to his relatively late age along with a slightly decreased acuity in his right eye all suggests ahistory of a mild anisometropic amblyopia on the right with partian sensory suppression of that eye chronically. At this time I am very comfortable with his overall progress. From the neurologist office visit notes dated 1/29/02, the opthalmologists feel that his gaze paresis is improving, his ptosis has resolved but he does have an esotropia. On exam, his right eye does tend to go in, he can make it go out by covering his left eye as can be demonstrated with the cover/uncover test. He  says he does tend to have some double vision when looking to the right. He does have a history of chronic decreased vision in the right eye but he has no history of double vision in the past and he feels that his right eye did not go in in the past. He is not having any trouble swallowing; he's not having any numbness in his extremities. He is taking TASA and 2 Advil, which the doctor recommended. The etiology of his illness is still not known although some people feel that it is related to his influenza vaccine. There is no good documentation of that nor is there any known incidence of this occurring. Whether this is an early presentation of MS is still uncertain.