Age: 19.0
Sex: F
Vaccine: MMR
Symptoms: Laboratory test abnormal, Malaise, Neck pain, Oral mucosal blistering, Paraesthesia
Clinical narrative: Information has been received from a health professional concerning a 21 year old female with no known allergies and on and off chest pain beginning in 2002 (attributed to stress), and a history of sinusitis, who on 5/20/04, was vaccinated in the left arm with a 0.5mL first dose of MMR (lot # 646343/0960N). On 5/20/04, the patient was given a 0.1 dose of PPD in the left forearm. On 1/5/05, the patient presented with a history of consistent tiredness and tingling up to 2 hours/day (left greater than right thigh). No weakness seemed to resolve. In June 2004, the patient experienced extreme fatigue. At the time of this report, the patient had not recovered. Unspecified medical attention was sought. No product quality complaint was involved. Follow up information received from a physician indicated that in the beginning of July 2004, the patient developed oral blisters. She also was noted to be ill with fatigue, rashes, head/neck pain, a tingling sensation, and weakness (noted to have recovered). She had escaped a specific diagnosis, despite numerous tests. Medical records indicated that the patient presented to the physician on 2/9/05 with multiple neurological symptoms. It was noted that beginning roughly in July 2004, the patient began to experience a series of problems, the first tingling in her lower extremities, but then went on to have symptoms of a feeling of diffuse weakness at times, a burning sensation across the right side of the head, as though she had trouble with her throat closing spontaneously, achy joints, and mostly extreme fatigue. The latter became particularly evident in the fall of 2004, when she had an axillary rash bilaterally, with itching. It was mostly a vesicular rash that had a somewhat linear vertical orientation. She had no had a rash elsewhere. Whereas her lower extremities tingling symptoms were very prominent in July 2004, lasting less that 30 minutes on a given occasion, they became much more of a persistent problem in December, and have bothered her since. In the meantime, she underwent an MRI scan of the brain which was performed on 12/28/04, without contrast. The study was normal. She also had an MRI of the thoracic spine on the same date, which was normal. During this time, she had not had any fever, though she had blood tests done, including a chemistry profile that was unremarkable, except for a fasting glucose of 61, but the subsequent glucose was 85 with normal insulin. In addition, a CBC diff was normal, and a mono screen on 1/5/05 was negative. On 2/9/05, the patient's albumin was high at 5.1g/dL. It was noted that the child had no childhood immunizations - were waived by parents. It was noted that the reaction was possible related to vaccination with MMR. The reporter indicated that the events were considered to be disabling. The reporter expressed a concern with the lot. The records of testing prior to the release of this lot have been checked and found to be satisfactory. The lot complies with the standards and was released. Additional information has been requested.