Age: 53.0
Sex: F
Vaccine: TD
Symptoms: Visual acuity reduced
Clinical narrative: While RN (PT) was removing stopper from prefilled DT syringe, requiring a pulling motion, when stopper released it caused a recoil of left hand (holding syringe) downward and plunger hit clerk and expelled contents to spray upward into face and burned her eyes. Patient is seen because of persistent neurological symptoms extending over a two month period of time. The patient was well, in her usual state of health with underlying conditions of hypertension and hypercholesterolemia with controlled hypertension. On June 8 the patient suffered a severe injury to her eye secondary to diphtheria tetanus toxoid being accidentally sprayed into her eye because of recoil when she removed a rubber stopper. The eyes were initially irrigated with normal saline and then 15 minutes in each eye with room temperature tap water. The patient immediately went to an ophthalmologist, was started initially on artificial tears beginning every hour tapering down to every 2-3 and then four times a day. The patient however, had severe symptoms and was seen again by the Dr. on June 13 and started on Lotemax at the time QId for three days. The patient resumed the tears on June 17. The patient persisted in having dry eyes, in spite of frequent administration of artificial tears. The patient in spite of very infrequent administration of artificial tears persisted in being dry. She was seen by DR. on June 24. Visual fields were accomplished at that time. It is interesting to note that the patients initial visual acuity was normal on the day that she first went to Dr. On June 13 the patient noted a difference in her visual acuity when tested by Dr. The patient was resumed on Lotemax on June 29 and was on it for seven days. The patient persisted in having symptoms of dry eyes and difficulty in visual acuity. She saw her ophthalmologist on June 11. A shirmer test at that time revealed no tear production and the patient was started on soothe with the recommendation for possible Restasis in the future. The patient did have new glasses prescribed at that time. On June 17 in the office developed a sudden feeling of paresthesias of both her fact and left arm. Because of the sudden onset of focal neurological symptoms, the patient was sent on an emergency basis to ER and seen by DR. Test at the time included an MRA of the brain, an MRI as well as a CAT scan. The patient's initial blood pressure was 200/100 although the blood pressure had been 130/90 in the office. The patient had been maintained on HCTZ 25 mg and K-tab 30 mEq with stable blood pressure for a significant period of time. The patient over the intervening next two months has had persistent left facial and left numbness occurring on an intermittent basis. At times the numbness of the arm is accompanied by weakness of the left arm as well. The patient has had intermittent episodes when this was proceeded by a lack of mental clarity. One particular severe episode occurred with lack of being able to articulate clearly, developing into not only facial numbness and left arm weakness but pain both in her face and left arm weakness and diaphoresis. The patients further evaluation during this period of time has included laboratory testing for vascular coagulation. Although minor variations were noted it was not felt by hematologist to represent any significant factor. The patient in addition underwent an echocardiogram of her heart and underwent a carotid ultrasound. The carotid ultrasound initially was read as having a fatty plaque on the right stenosis and no evidence of friability of the plaque and no ulceration. The patients additional evaluation has included an EEG, based on the fact that many of these episodes but not no all were proceeded by a sense of weakness and lack of mental clarity and profound fatigue after the event. The EEG along with photic stimulation has been negative. The patient had a repeat MRI and gad, showing UBO's but not in a pattern suggestive of MS. The patient has not had a spinal tap for evaluation of possible MS. We are left with a very puzzling and disturbing series of events. (1) The patient has suffered what appears to be permanent eye damage in terms of lack of tear production and difficulty with vision and eye pain. (2) We are left with intermittent neurological symptoms involving her left arm and left face for which no clear etiology has been established. Interestingly the left facial symptoms can occur alone but the left arm symptoms always occur after the facial weakness occurs. I would very much appreciate your evaluation of these symptoms. Certainly the patient is finding it difficult to conduct her life with this degree of uncertainty. What concerns me is the fact that these symptoms followed a contact with diphtheria tetanus in her conjunctiva which resulted certainly in eye symptoms. Neurological symptoms have been associated with the diphtheria vaccine but there is no way i can be certain whether this is causal or not. I would very much appreciate further evaluation of these symptoms in what ever way you think is appropriate. The patient although hypertensive, has never shown an association between hypertension and occurrence of these neurological events. Initially we had changed the hypertensive medication during this period of time from her HCTZ and potassium to an ARB plus HCTZ which resulted in hypotension and ARB alone resulted in lability of blood pressure, It was elected then to put her on calcium channel blocker followed in a period of time with a smaller amount of diuretic and potassium. The patient in the past had been intolerant of ACE inhibitors because of the cough. The changes in medication did not appear to correlate in any way with symptomatology, Attempts to controlling weakness with Lipitor which resolved on discontinuation of this medication. This was in her past history and not related to the current episode. Additional test for evaluation included that of an echocardiogram of her heart.