Age: 60.0
Sex: M
Vaccine: LYME
Symptoms: Pharyngitis, Rash
Clinical narrative: Report A0359645A describes palindromic rheumatism in a 60 year old male who received Lyme disease vaccine recombinant OspA. This report was received as part of litigation proceedings with forwarding of medical records. The subject submitted a report directly to VAERS. Medical history included possible Lyme disease 1997, multiple arthralgia syndrome 1997, Heberden's and Bouchard's nodes in the hands 1998, hypertesnion, polyarthritis 1997, low back problems, sore hands "especially at end of day," and chronic obstructive pulmonary disease. Surgical history included fractured left ankle, allergic rhinitis, tonsillectomy, appendectomy, and hernia repair. The pt smoked one pack of cigarettes per day for forty years. Family history was significant for rheumatoid arthritis in two maternal aunts, one of whom was disabled by it. Concurrent medications included Wellbutrin SR, Flonase, doxepin, Cytotec, Xanax, Plendil, Relafen, acetylsalicylic acid, azithromycin, Advair, and Viagra. On 4/23/99, the subject received his first injection of LYMErix (123B9). At that time, he reported "sore hands, especially end of day." The medical record did not indicate that the pt had experienced adverse events following the immunization. On 7/15/99, the subject received his second injection of LYMErix (123B9). In a Statement of Injuries, his attorney alleged that the subject "suffers from flu-like symptoms, severe random joint pain and swollen joints, sore throat, nausea, rashes, and nerve problems in his hands." The following info was obtained from medical records. On 10/5/99, the subject presented to the vaccine provider with a chief complaint of all over, hands, feet, legs, ankles; neck can't turn" for one month.  The physician noted "increased symptoms after finishes working-stiffness neck, shoulder, wrists significantly worse than baseline stiffness." On physical examination, the physician noted that wrists, elbows, hips, knees, and ankles had good range of motion without pain. C-reactive protein concentration and rheumatoid factor were elevated. Antinuclear antibody titer was positive. The physician's diagnosis was arthritis. On 10/11/99, the physician noted, "labs positive for inflammatory arthritis." The vaccine provider referred the subject to a rheumatologist." The subject remained under the care of the vaccine provider until at least 4/11/02. During this time, the subject reported "intermittent arthralgias-similar to prior Lyme symptoms" and "diffuse migrating joint pains." Lab analyses revealed abnormalities. On only one occasion, the physician noted "trace edema." The physician made diagnoses of "arthralgias," "palindromic rheumatism," "DJD," possible Lyme disease and "RA." He prescribed Celebrex, tetracycline and administered a single 0.1mL injection of Aristocort. He referred the subject to an orthopedist. The subject requested a referral to another rheumatologist. On 11/30/99, the subject was evaluated by the rheumatologist. The physician noted that the subject had "a chronic palindromic arthropathy since the fall of 1997. Initially he developed an acute symmetric polyarthropathy involving large and small joints, which did not respond to conservative treatmetn with nonsteroidal medications and because he had a risk for developing Lyme disease. It was felt that he might have Lyme disease. He was treated for a period of 90 days initially with oral antibiotic therapy and then IV antibiotic therapy for a month and then back for another course of oral antibiotic therapy. Eventually his articular symptoms resolved. During the entire course, his Lyme titer was never positive but he was given antibiotic therapy after a month after his symptoms began. nevertheless, he did well, ultimately requiring the addition of doxepin for improved sleep until August of this year, when he had a recurrence of more symptoms, again in a symmetrical nature involving primarily the PIPs of both hands and wrists and stiffness after long periods of rest of a significant degree. He was told this time that his rheumatoid factor is now positive, although it had not been when he was previously tested. He also noticed severe stiffness in his neck, especially with lateral rotation, which was never present before. He has had no other extra-articular sympotms, such as xerostomia, fevers, weight loss, or neuropathic symptoms." On physical examination, "cervical spine rotation is limited bilaterally as is lateral flexion significantly. Dorsal spine reveals no abnormal curvatures and full range of motion. "L-S spine motion reveals slight limitation. Hips have full range of motion. Appendicular skeleton-elbows have full extension. No nodules or swelling. Wrists reveal slight limitation in extension bilaterally. No tenderness over the ulnar styloids. No gross deformity of the small joints of the hands, although there is some fullness about the MCPs. There are some degenerative cysts about several of the IP joints bilaterally. There is no palmar erythema and grip strength is slightly limited only. Knees reveal no weight bearing deformity. No fluid and no instability. Ankles are normal. There is no deformity of the forefoot, sucha, dactylitis, or deformity of the midfoot and hindfoot. Tender point exam was negative. The rheumatologist stated, "It is not clear at this point whether or not the pt truly has Lyme disease, although I think treatment was appropriate. All along he may have had Rheumatoid arthritis with a palindromic setting. There may have been an element of fibromyalgia probably as a secondary concomitant form." The physician discontinued nabumetone therapy, and prescribed methotrexate and ibuprofen. The subject was evaluated by a second rheumatologist on 2/22/00. At that time, "he is complaining of having pain in both knees, wrists, ankles, temporal mandibular joints, shoulders, posterior aspect of the neck, hips. The pain is worse at night. Upon getting up in the morning he claims to be asymptomatic. Morning stiffness lasting +1-15 minutes. The pt had sleeping pattern disturbances that went away after he started taking Doxepin. The pt claims that stress worsens his pain. Did not notice any difference in the pain with different weather patterns." On physical examination, the cervical spin had full range of motion. "There is Heberden and Bouchard nodes in the fingers of both hands. There is bilateral complete hand grip. Wrists, elbows, and shoulders are within normal limits. Hips with full range of motion. Knees there is mild effusion of both knees with positive bulge sign. There is some crepitation on passive motion. Ankles are unremarkable. Feet, there is mild bilateral talus, valgue, slightly worse on the right side." The physician's impressions were "suspect palindromic rheumatism. Osteoarthritis of the small joints of the hands. Bilateral talus valgus. Rule out osteoarthritis of both knees if indeed this is palindromic rheumatis, since he has a positive rheumatoid factor, this could become full blown rheumatoid arthritis later on. The physician prescribed Celebrex. The subject remained under the care of this rheumatologist until at least 1/3/02. During that time, he experienced talalgia upon waking up. The physician noted "coarse crepitas on passive motion in both knees." The physician made additional diagnoses of "early osteoarthritis of both knees," "considering the increasing type of rheumatoid factor, I will think that this pt will develop full-blown rheumatoid arthritis in the near future," and "Plaindromic rheumatism versus early rheumatoid arthritis that can be well controlled." The physician prescribed physical therapy, misoprostol, prednisone, sulfasalazine, and salsalate. As of 1/3/02, the subject was taking salsalate, sulfasalazine and prednisone. He "claims to be pretty much asymptomatic except for some vague hand pain, occasional right wrist pain." The subject was evaluated by an orthopedist on 7/26/01. The physician noted that the subject "began developing multiple joint complaints in the jaw, wrist, shoulders, neck and knees in September of 1997. He did not remember any type of tick bite. He also had a negative Lyme test previously. Another physician treated him with 28 days of IV antibiotics and 76 days of oral antibiotics in 1997 with a presumptive diagnosis of Lyme disaease based on him having 19 of 26 possible symptoms. At the end of the antibiotic course he stated he was asymptomatic. He has had the symptoms since 1999 when things began to relapse. They have been at multiple sites. He also developed a rash over the left anterior foot and ankle area." On physical examination, the physician noted "his knees have some patellofemoral crepitation. There is no synovitis or effusion. He does have multiple symmetrical inflammatory arthropathy in the hands affecting the DIP and PIP joints with minimal deformity and no morning stiffness. He does get stiffness in his hands after activity. His shoulder motion was good. He did not have impingement or humerocromial crepitation. He had full pain free range of motion of the wrist bilaterally. He had full pain free range of motion of the neck. He did have an upraised erytjematous type rash over the left foot and ankle area." X-rays of the left knee and hands wee abnormal. The physician's impressions were: diagnostic dilemma with question of Lyme disease, palindromic rheumatoid arthritis as diagnosed by the second rheumatologist. Rule out occult alternative rheumatological diagnosis." The orthopedist referred the subject back to the second rheumatologist. Following the reported onset of joint pain, the subject experienced microscopic hematuria, bronchitis, allergic reaction to Celebrex, seborrheic keratoses, myositis of the groin, diarrhea, and hhypercholesterolemia. The most recent info, received on 6/11/02, did not provide the outcomes of the reported events.