Age: 53.0
Sex: M
Vaccine: LYME
Symptoms: Influenza like illness, Lumbar spinal stenosis, Musculoskeletal pain, Nervous system disorder, Nuclear magnetic resonance imaging normal
Clinical narrative: This case was reported by a lawyer and described the occurrence of joint pain in a male subject of unspecified age who was vaccinated with LYMErix, GlaxoSmithKline for prophylaxis. A physician or other health care professional has not verified this report. The subject's medical history, concurrent conditions and concurrent medications were not reported. On an unspecified date the subject received unspecified dose of LYMErix (unknown). An unknown amount of time after vaccination with LYMErix (unknown). An unknown amount of time after vaccination with LYMErix, the subject experienced joint pain, flu-like symptoms, autoimmune disease, activities of daily living impaired, memory loss, headache, joint inflammation, rheumatological symptoms, neurological impairment and cognitive impairment. At the time of reporting the outcome of the events was unspecified. Follow up information was received on 23 July 2007 via medical records. The subject was a 53 year old male who was vaccinated with LYMErix on 21 January 1999, 25 February 1999, and 25 March 1999 (inappropriate schedule of vaccine administered). Medical history included migraine headaches, reported "congenital" spinal stenosis, hyperlipidemia, and hypertension. On 29 June 1999, the subject presented with a "reaction to Lyme vaccine" manifested by muscle and joint pain since receiving the third LYMErix injection. On 24 May 2000, diagnostic tests were positive for HLA DR4. In a letter dated 01 February 2001, the subject reported ongoing joint/ tendon pain since vaccination with LYMErix, with "moderate" relief from physical therapy. On 14 April 2003, physician's assessment was lumbar radiculopathy. On 17 April 2003, the subject was hospitalized and underwent decompression for congenital lumbar stenosis associated with lumbar disc herniation, following a one to two year history of increasing back pain. Lumbar pain was treated with Medrol Dosepack and OxyContin. On 04 June 2003, he reportedly experienced improvement in sciatica, and continued with physical therapy. on an unknown date, the subject underwent rotator cuff repair and lumbar laminectomy for spinal stenosis. He was seen for orthopaedic follow-up on 08 March 2004, one year post L4/5 laminictomy for congenital spinal stenosis and neurogenic claudication. It was noted that postoperative course had been difficult without resolution of right L5/S1 distribution pain despite adequate decompression. He experienced significant stenosis at L2/3 and L3/4, but denied back pain. He was again evaluated in April 2004 for continued lower back pain upon standing, radiating to the right posterior leg and down to the lateral foot and toes. He reported that he was electing to undergo surgery of the upper lumbar roots to release the pressure of spinal stenosis visible on magnetic resonance imaging (MRI). On 28 April 2004, one week post-decompression for congenital spinal stenosis at L2/3 and L3/4, the subject experienced muscle spasm of the lower back radiating to the right hip. Treatment included OxyContin. The subject reported events the Vaccine Adverse Event Reporting System (VAERS #178611). In January 2004, an echocardiogram showed mild left ventricular hypertrophy with normal systolic function consistent with hypertensive changes. In February 2005, the subject was hospitalized due to acute pancreatitis. These were considered to be incidental findings upon medical record review.