Age: 43.0
Sex: M
Vaccine: LYME
Symptoms: Liver function test abnormal, Muscle twitching, Nervous system disorder, Pain, Red blood cell sedimentation rate decreased
Clinical narrative: The pt received Lymerix on 4/13/99, 5/10/99 and 7/6/99. The 3rd injection was given 3 months following the 1st injection, rather than the recommended interval of 12 months. The pt presented to his PCP on 4/27/00 with a 1 week history of "on and off" numbness of the left forearm and head. Each episode of numbness lasted a "few" seconds. during exam by the physician, the vaccinee felt numbness over the left volar surface "on 1/2 radial side forearm and half radial on side palm of left hand". The numbness lasted "for a few seconds and disappeared." The physician noted "normal" function of the left hand. On 1/26/00, the vaccinee present to the local ER.hereported that he had been bitten by a tick two weeks previously, and had beenexperiencingfatigueand increasing joint discomfort for the past week.Total Lyme antibody screen was positive. Complete blood count revealed decreased red blood cell count and mean platelet, volume and elevated mean corpuscular hemoglobin. The ER physician made a diagnosis of "Rule out Lyme disease", prescribed doxycycline 100 mg twice a day for 11 days and referred the vaccinee to his primary physician. The vaccinee returned to the ER on 06/23/00 requesting Lyme Western blot analyses. At that time, he reported that arthralgia and fatigue had been present for six weeks, rather than one week. The vaccinee returned to the emergency room on 07/14/00, where a live tick was removed from his back. On 01/06/01,the vaccinee was seen by an optometrist, who noted that he was receiving hydroxychloroquine was seen by an optometrist, who noted that he was receiving hydroxychloroquine therapy for the treatment of Lyme disease. The pt was evaluated by a clinical neuro-psychologist on 1/29/01 "for diagnostic neuro-psychological exam to determine the possible presence of impairments of higher cortical functioning of the brain as the pt has received Lyme vaccine which was followed almost immediately by depression and cognitive decline. He is being evaluated to determine the presence of a Lyme encephalopathy. In 4/99, he began experiencing psychiatric symptoms involving what he thought was a mild depression. During March through 10/99, he experienced worsening of pain in his right elbow. He was told that it was likely tennis elbow but cortisone shots did not help. He was experiencing joint pain, which involved both upper and lower extremities by 1/00. He developed a twitch in his right eye area that lasted for 2 to 3 weeks. He was also struggling with moodiness, weight gain, sleep difficulty and fatigue. He noted his cognitive abilities, particularly memory and attention, were declining. In 5/00, he went to the ER and asked for a Lyme test, which was positive. He started on doxycycline for 2 weeks before he was switched to Ceftin and Biaxin. On exam, a mild bilateral upper extremity tremor was noted. He also noted a mild depression. Overall, the pt's exams together with history provided, indicate the presence of a mild to moderate sub-acute encephalopathic process, as seen in CNS Lyme disease. The decision to put him on IV Rocephin was reached after he had an elevated protein CSF. We will treat him from 8 to 12 weeks. The neurologist noted "no significant progress in his achiness and general level of energy. We are going to complete his treatment by additional 4 weeks of IV Rocephin. He is going to continue with his oral Biaxin and Plaquenil through this treatment. He has not worked since 4/1/01. He saw the neurologist on 6/22/01 and was no better. In any event, we are going to give him a trial with Flagyl which is non-conventional for Lyme encephalopathy. Therapy began on 7/27/01 at a dosage of 375mg twice daily. A month later, he did not feel as depressed as he was before. On 8/21/01, the Flagyl was increased to 500mg twice daily. In a Statement of Injuries, his attorney alleged that the pt "suffers from pain and inflammation in his elbows and knees, tingling in his hands and arms and a facial twitch about his eye which has resulted in failing vision. (He) suffers from extreme fatigue. In addition, (he) suffers from cognitive difficulties, including problems with his memory, problems focusing, poor executive function and mood swings". Lyme disease in this report is considered disabling/incapacitating because the pt reported that he was unable to work for at least 6 weeks.