Sex: F
Vaccine: HPV4
Symptoms: Lipids normal, Nerve conduction studies normal, Nerve stimulation test normal, Nuclear magnetic resonance imaging brain normal, Nuclear magnetic resonance imaging spinal abnormal
Clinical narrative: Information has been received from the authors of the article, concerning a fourteen year old adolescent girl who was presented with intractable generalized burning and tingling sensations for 1.5 years. The patient has no significant past medical history except for stomatitis with fever from HSV and has been taking VALTREX for three years. Her vaccination history includes DTaP (unspecified), Hepatitis A vaccine, Hepatitis B vaccine, influenza nasal, meningococcus, MMR, polio, Tdap (unspecified) and varicella before year 2014, with no subsequent complication. Then the patient was administered with GARDASIL on 10-JUL-2014 and 07-OCT-2014 (dose,strength, vaccination site, route unspecified) in which she started to have pain on 19-JUL-2014. The symptoms began in the lower back and progressed to all extremities 9 days after GARDASIL vaccination. The pain persisted despite various pain medications. No weakness, gait impairment or automatic symptoms were noted. On examination in approximately July 2014, of cranial nerves, strength, tendon reflexes, and cerebellar testing were normal. Sensation was decreased to pinprick on distal lower extremities in a symmetric stocking-glove distribution. Vibration and proprioception sense were normal. There was no rash, erythema, swelling, or skin lesions. Motor and sensory nerve conduction studies were normal in the arms. She did not tolerate the studies in the legs. MRI (Magnetic resonance imaging) Brain with and without contrast, MR Face, Orbit with and without contrast, and MR Cervical, Lumbar spines with and without contrast were all normal. MR T-spine showed a small syrinx from T8-T9 and slight T10-T11 disk bulge. Skin biopsy of the right thigh and foot showed low INFD of 9.69 and 7.17, respectively. The sweat gland nerve fiber density showed normal values of 43.5% and 48.7%, respectively. Other causes of neuropathy were negative, including family history, toxin exposure, antinuclear antibodies, extractable nuclear antigen antibodies, rheumatoid factor anti-Ro (SS-A), sedimentation rate, C-reactive protein, vitamins B12 and E deficiency, diabetes, thyroid, lipid storage disorders, glycogen storage disorders, copper, and hepatitis. Serum IgM binding to myelin-associated glycoprotein and tri-sulfated heparin disaccharide were negative. As evidenced by abnormally low intraepidermal nerve fiber density (INFD) in the skin biopsy, it was suspected that, the patient has SFN possibly in temporal association with the GARDASIL. Other differentials were herpes neuralgia and thoracic syrinx. However, these differentials did not fully explain her generalized dysesthesia. The outcome of the event small fiber neuropathy was unknown. Conclusion: The possible association between vaccination and small fiber polyneuropathy is not well defined; moreover, the lack of epidemiological data supporting association between vaccination and SFN require that these mechanistic evidence must be carefully reviewed. Because the symptoms of SFN are predominately subjective sensory symptoms, the incidence of Small fiber neuropathy after vaccination is difficult to quantify based on reports alone. Although the diagnosis of SFN can be a clinical diagnosis, dysesthesia following vaccination can be because of various causes, such as local inflammation or transient immune-mediated phenomena. A copy of the published article is attached as further documentation of the subject's experience. Additional information has been requested.