Age: 37.0
Sex: F
Vaccine: DT
Symptoms: Injection site pain, Intervertebral disc degeneration, Muscle spasms, Muscular weakness, Musculoskeletal stiffness
Clinical narrative: Initial report received from a consumer on 08 May 2009, who is also the patient's parent. A 37-year-old female patient with an unknown medical history, had received a booster dose left arm injection of DECAVAC, lot number U2348CA on 21 April 2009 and approximately 20 hours later, she developed stiffness on the left side of her neck with a deep burning sensation with numbness and tingling down the left arm which also extended to the left leg. The event required a doctors visit and the patient was reported to have been hospitalized three times (dates not reported); and she was hospitalized at the time of the report. Per the reporter, the patient had a seizure (date of onset and duration not reported) and tests had been performed to rule out stroke and a brain tumor. According to the reporter, the MRI "doesn't show anything". The patient's recovery status was unknown and the reporter declined to provide any additional information at the time of the report. Follow-up information was received from the patient's physician on 16 June 2009. The patient had a history of ,motor vehicle accident five years earlier with ongoing neck pain, depression, anxiety, bronchial asthma, and obesity. Family history included Ramsay-Hunt syndrome (daughter) and lung cancer (father). On 22 April 2009, one day post-vaccination, she presented to her physician with complaints of pain at the injection site, left hand tingling, and pain in the left side of her face and neck. Her physician advised her to take MOTRIN and BENADRYL every eight hours, and to go to the emergency room if symptoms did not improve. On 23 April 2009 she presented to the emergency department with neuropathy and vertigo. A CT of the head was normal, and she was directed to follow-up with a neurologist. On 25 April 2009 she was seen by her primary care physician again, and complained of ongoing symptoms with facial numbness and headache. No redness, induration, or infection was noted at that time. On 27 April 2009 she presented again to the emergency room with complaints of a severe tingling and burning sensation in the left hand, areas of numbness in the left arm and left second dorsum, dizziness, polyopia, and an inability to see clearly out of the left eye. Upon exam, the patient was noted to have an area of induration on the left deltoid, and left grip strength was slightly decreased. The patient was able to move both hands equally. Testing at that time showed a sed rate of 30 and a normal ECG and chest x-ray. On 28 April 2009, an MRI of the left brachial plexus was unremarkable. MRI of the cervical spine showed moderate broad-based bulging of C5-C6 intervertebral disc and mild kyphosis. MRI of the brain was essentially normal. Echocardiogram showed mild mitral and tricuspic regurgitation. She was discharged from the hospital on 29 April 2009, with a diagnosis of vertigo and left upper limb radiculopathy. On 01 May 2009 she began physical therapy at home, at which time she was using a hemi-walker and was noted to have dyspnea on exertion. She also began to complain of urinary retention, and on 02 May 2009 had shortness of breath with chest tightness. On 03 May 2009 she was readmitted to the hospital, with complaints of ongoing left upper arm tingling, numbness, left lower extremity weakness, trunk jerky movement, and right lower extremity numbness. She was seen by a neurologist, who concluded that there was not organic disease. Reassurance and physical therapy was recommended. The patient subsequently refused to cooperate for further examination. She was admitted with "multiple inconsistent complaints, non-organic in origin", depression, multiple social and family issues, and possible obstructive sleep apnea. Lumbar spine MRI was normal, and the patient was discharged on 04 May 2009. On 06 May 2009 she presented to a different emergency department, with complaints of left-sided weakness and cramping, and seizure. She also noted progressive shortness of breath, described as muscular. Neurological consult on 07 May 2009 noted mainly sensory changes and weakness on the left side of her body, and the current presentation was noted to occur within the context of significant personal stress. The neurologist stated that "there are no changes in imaging that may suggest that this presentation may be associated with vaccination that she received at the end of April". Treatment included ULTRAM, increased gabapentin, CYMBALTA, and baclofen. She was also noted to have a urinary tract infection, and began treatment with CIPRO. MRI of the brain and MRA of the brain and neck on 07 May 2009 were essentially normal. MRI of the cervical spine on 08 May 2009 showed "mild reversal of normal cervical lordosis and degenerative disc disease at the C5-C6 level, without significant spinal canal stenosis or neural foraminal narrowing". She was discharges on 08 May 2009 feeling "much better", although she continues to experience pain in her upper and lower left extremities. Additional laboratory testing performed on 25 and 26 May 2009 was within normal limits. Additional information was received from the health care professional on 19 October 2009. Per the reporter, the patient had undergone extensive diagnostic testing and examination by a specialist, none of the results indicated a diagnosis of seizure. As a result, "seizure" was not considered to be an event. The reporter had not noted any induration.