Age: 53.0
Sex: M
Vaccine: LYME
Symptoms: Arthralgia, Fatigue, Headache, Laboratory test abnormal, Muscular weakness
Clinical narrative: This report describes the occurrence of muscle and joint weakness and pain in a 53 year old male who was vaccinated with Lyme disease vaccine recombiant OspA (LYMErix). This report was received as part of litigation proceedings with forwarding of medical records. The subject's medical history included allergies to penicillin, levofloxacin, and fluticasone nasal spray. The medical history also included bipolar depression, alcohol and unspecified drug abuse (the subject was reportedly clean since 1985), tobacco use, hepatitis C infection, chronic diarrhea, hemorrhoids, sexual dysfunction, minimal bilateral hydrocele, obstructive sleep apnea, traumatic nasal septum deviation, bilateral inferior turbinate hypertrophy, chronic sinusitis, chronic rhinitis, hoarseness, vocal cord polyps, traumatic amupations of three fingers on three separate occasions, cervical spondylosis, significant degenerative arthritis of the cervical spine, traumatic arthritis of the left wrist, knee pain, neck pain, tears of the left lunato triquetral and TFC tendons, grade II lumbar sprain/strain, shoulder pain, shoulder muscle spasms, low and mid-back pain, back spasms, sacroiliac pain, numbness in both arms and fingers, traumatic neuroma of the right index finger, and left carpal tunnel syndrome. Surgical history included tonsillectomy, adenoidectomy, appendectomy, replants of the left fifth and right fourth fingers, repair of a tear in the left TFC ligament, partial synovectomy of the left wrist, debridement of an osteochondral lesion in the left wrise, nasal septoplasty, exicsion of bilateral vocal cord polyps, turbinectomy, uvulopalatopharyngoplasty, revision of the traumatic amputation of the right index finger, and neuroma excision from the right index finger. Concurrent medications included lithium carbonate, sildenafil, paroxetine, and zolpidem. The subject received injections of LYMErix on 5/22/00 abd 6/19/00 (lot numbers not recorded. In a statement of injuries, the subjects attorney alleged that the subject suffers from muscle and joint weakness in his knees,hips and neck. In addition, his knees often buckle. Also he experiences frequent headaches. He also suffers from fatigue. He had a rash for the first 6 months after the shot. The rash was on his armpits, elbows, and groin. The following information was obtained from medical records. The subject presented to the vaccine provider on 9/27/00 with complaints of joint and muscle pain times two weeks, frequent voiding. The physician' impressions were R/O UTI, Viral, ?imflammatory. The physician prescribed naproxen and moxifloxacin. The subject remained under the care of this physician until at least 12/27/01. During this time period, the subject reported entire body hurts and pain in the lower back and left leg after a slip. On 6/11/01, the subject reported that he was being treated for Lyme disease with a three month course of doxycycline. On 10/31/01, he reported that he was taking another three month course of doxycycline. Testing for HLA-DR4 was positive. A lumbar spine x-ray revealed abnormalities. Please see lag data section. The vaccine provider made diagnosis of R/O RA, R/O Lyme, Chronic pain, and Left LE radiculopathy. He prescribed rofecoxib and referred the subject to a rheumatologist, an infectious disease specialist, and a chiropractor. From 2/5/01 until at least 12/10/01, the subject was under the care of a chiropractor. During this time, the subject reported cervical, thoracic, and lumbar pain; lower back spasms, and leg pain. On 6/1/01, the subject reported that he's in constant pain (joints/muscle) secondary to LYMErix injection in 11/00. On 12/7/01, he reported intense left L5 radiculopathy times two weeks after slipping on a spot of oil. On 11/21/01, the subject told his urologist that he recently completed ninety days of tetracycline for Lymes'