Age: 0.52
Sex: M
Vaccine: DTAP, HBPV, HEP, OPV
Symptoms: Impulsive behaviour, Laboratory test normal, Mental retardation severity unspecified, Mixed receptive-expressive language disorder, Negativism
Clinical narrative: This case was reported by a lawyer and described the occurrence of nerve injury in a male subject who was vaccinated with Engerix B, DTPa-HIB, OPV, MMR II, Varivax. The subject was vaccinated with Engerix B on 14 February 1996, with Recombivax HB on 11 April 1996, and with Engerix B on 20 August 1996. According to the legal complaint, at an unspecified time after vaccination with hepatitis B vaccine, the subject experienced "serious and permanent neurological injuries" which were "alleged to be caused by Thimerosal." In February 2000, the subject was diagnosed with severe communication disorder (autism spectrum disorder). In May 2001, the subject was diagnosed with autism with overlap of attention deficit hyperactivity disorder (ADHD). The subject was also diagnosed with a neurodevelopmental disorder on an unspecified date. This case assessed as medically serious. Follow up information was received on 30 March 2007 via medical records. On 02 June 1998, the subject was evaluated by a pediatrician for parental concerns that the 27 month old subject was speaking only two words. Notes indicated "rule out speech delay, rule out hearing loss". On 26 June 1998, a speech and language evaluation was conducted. results included mild delays in auditory comprehension, receptive language, expressive language, and total language with normal expressive communication skills. It was noted that the subject yelled or engaged in aggressive behavior instead of using language when frustrated. Recommendations included weekly speech therapy. On 02 July 1998, the subject underwent a developmental evaluation within the home, and demonstrated significantly delayed mental skills for his age, with language, cognitive, fine motor, sensory processing, and attending skills of specific concern. It was noted that he experienced difficulty attending to tasks and became easily frustrated. Recommendations included speech intervention and occupational and developmental therapy. An occupational therapy evaluation revealed slightly low muscle tone in the trunk and upper and lower extremities, and concerns included sensory processing and hand-eye coordination which were assessed to be "influencing the development of age appropriate sensory motor skills". According to progress notes dated 23 July 1998, the subject had been identified as having a speech delay by his daycare provider. In May 1999, the subject was referred for review and update of developmental assessments. Developmental testing revealed a significant mental delay with relative strengths in nonverbal problem solving/ reasoning, while tasks involving verbal comprehensive and expressive language were more difficult. The evaluated stated that "at this point, the special education category of autism is appropriate for (subject)". On 09 June 1999, the subject returned to his pediatrician for evaluation for evaluation of unclear speech described as "somewhat of a speech impediment". At that time, the subject was enrolled in speech therapy. A psychological consultation was performed on 21 July 1999 for the purpose of educational placement. He exhibited oppositional behavior at times, and was noted to initiate joint attention with adults, although he did not do so with peers. Evaluation on 23 November 1999 indicated "loss of many developmental milestones especially expressive language", and during the course of examination the subject was "chaotic" and inattention. The subject struck his mother and the examining physician several times, and attempts to control the child resulted in "explosive behavior from the child with screaming and spitting at mother". The evaluating physician also observed that "lack of continuity had contributed greatly to the chaotic nature of this patient's medical record", and recommended that the subject be assigned a single pediatric provider. On 21 December 1999, concerns included developmental delay and speech delay. The subject was seen for developmental follow up on 15 February 2000. During the preceding year the subject had been enrolled in a program with children with autism. Speech development had been slow to improve,a nd his vocabulary included approximately 50 words. He was socially rough with other children, and motor skills were  assessed as "not a concern". His mother reported treatment with vitamin A in the preceding "couple" of months, and it was noted that at 35 months of age mild conductive hearing loss bilaterally had been identified. An audiological examination on 15 February 2000 yielded normal findings. He continued to exhibit a short attention span and impulsivity. He was diagnosed with severe communication disorder (autistic spectrum disorder), and medications at that time included Bethanechol and cod liver oil. A progress note dated 27 March 2000 indicated as assessment of autism disorder. At that time he was receiving home health care for behavioral management, and was reported to be "less hyperactive" on therapy with Clonidine. By 11 November 2000, he had been weaned off Clonidine,and treatment with risperidone was initiated. The mother noted no subsequent improvement in socialization, and Adderall was added on an unknown date. In January 2001 and February 2001, the subject underwent a psychological assessment through his school system. At the time of evaluation, he continued to participate in speech and language services, occupational therapy, and motor development. According to the combined testing including the Stanford-Binet Intelligence Scale, the Bayley Scale of Infant Development, and the Vineland Adaptive Behavior Scale, the subject was functioning cognitively and adaptively in the "mentally deficient" range. According to the evaluating psychologist, the subject met the criteria to be diagnosed as mentally retarded. During a developmental consultation on 25 May 2001, the mother reported that the subject had been receiving a "magnesium/ calcium preparation that was thought to improve cognitive skills". The subject was noted to be very aggressive, with behavior improved on risperidol therapy. He exhibited "typical" autistic behaviors including little or no eye contact and kicking or hitting during the physical examination. Testing on that date revealed a "typical" pattern of autism with an overlap into the ADHD spectrum. Upon examination on 17 August 2001, the subject was described as "busy and defiant". At five years old, following detection of a heart murmur, the subject was diagnosed with left ventricular hypertrophy with repolarization abnormality,a nd right bundle branch block by electrocardiogram. These were considered to be incidental findings upon medical record review.