Age: 18.0
Sex: F
Vaccine: HPV4
Symptoms: Neuropathy peripheral, Nuclear magnetic resonance imaging brain normal, Nuclear magnetic resonance imaging spinal normal, Orthostatic intolerance, Pain in extremity
Clinical narrative: Information has been received from the authors in a published literature article, concerning an 18-year-old healthy female experienced numbness and tingling in the right arm 3 weeks after receiving the first GARDASIL vaccine injection into the right deltoid muscle. Over the following 3 months, she developed lower back pain, neck stiffness and pain in the legs resulting in difficulty sitting in class. Diagnostic tests obtained at that time included an unremarkable nuclear magnetic resonance imaging (MRI) of the cervical and lumbar spine and elevated Antinuclear antibody (ANA) titers of 1:320 with speckled and homogeneous pattern. Despite the symptoms experienced after the first injection, she received a second GARDASIL vaccine 3 months after the first injection, which resulted in significant exacerbation of previous symptoms. Additional symptoms, such as fatigue, orthostatic intolerance, dizziness, urinary incontinence and blurry vision appeared which in conjunction with pain and numbness resulted in significant functional impairment. In fact, the patient became wheelchair bound at that point and had to take medical leave from college for a full semester. Bedside heart rate assessment revealed a supine heart rate of 88 bpm and a maximum heart rate of 128 bpm within 5 min of standing. Neurological examination demonstrated reduced temperature sensation in the hands and feet without motor weakness. MRI of the brain, cervical, thoracic and lumbar spine, electromyography and cerebrospinal fluid analysis were unrevealing. Serological tests were only remarkable for elevated ANA titers. Based on clinical presentation, the patient was diagnosed with Postural orthostatic tachycardia syndrome (POTS) and possible small fiber neuropathy; a tilt table test and further autonomic reflex screen testing were not performed. Patient outcome was recovering since it was reported that over the following 3 years, the patient's symptoms improved significantly with the use of duloxetine and doxepin for neuropathic pain, and she was able to return to college full-time. Nevertheless, none of the patients experienced complete resolution of symptoms, and all patients continued to experience some residual symptoms. Possible pathogenesis of the new onset POTS after vaccination may include the mechanism of molecular mimicry, whereas Human papillomavirus (HPV) vaccine epitopes may induce formation of cross-reacting antibodies against potential targets of the autonomic ganglia, neurons, cardiac proteins or 31 1/2-adrenergic and M2/3 muscarinic receptors. Additionally, induction of bystanding lymphocyte activation and a broad spectrum of cytokine responses elicited by the HPV vaccine may also be involved. The reporter stated that the temporal association between vaccination with GARDASIL and the onset of symptoms of POTS in healthy young women is significant and deserves further investigation for assessment of a possible causal relationship. Postural orthostatic tachycardia syndrome was AND Neuropathy peripheral considered disabling. This is one of several reports from the same literature: 1007USA02012. Additional information has been requested.