Sex: M
Vaccine: HEP, HEP, HIBV, MMR
Symptoms: Hypoacusis, Lymphocytosis, Mental retardation severity unspecified, Nasopharyngitis, Otitis media
Clinical narrative: Information has been received  from medical records regarding a case in litigation concerning an 11-month-old male whose mother did not have prenatal care and who have depression.  He was born at 40 weeks gestation without complications and has no known allergies.  On 17-JUL-1998 he was vaccinated intramuscularly with a first 0.5 ml dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown).  The second, third and fourth doses of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown).  The second, third and fourth doses of hepatitis B vaccine rHBsAg (yeast) (manufacturer unknown) were given on 16-JUL-1999, 17-DEC-1999 and 21-JUL-2001.  Secondary suspect vaccinations included the first, second and third doses of Hib conj vaccine (manufacturer unknown) given on 18-MAR-1999, 16-JUL-1999 and 17-DEC-1999.  At 16 months of age he was seen by a physician at a well examination and a developmental evaluation revealed some  slight developmental delay.  Following the examination the patient received services to increase his developmental skills, services included occupational, physical and speech therapy.  An audiological evaluation was attempted on 06-JUN-2000, the responses were inconsistent and a mild loss was suspected.  On 26-JUL-2001, at 3 years of age, the patient was diagnosed with autism.  Subsequently, vaccination with diphtheria toxoid (+) pertussis vaccine (unspecified) (+) tetanus toxoid dose number 4 was omitted due to suspicion of problems from the vaccine.  On 06-SEP-2002, at 4 years of age he was diagnosed with pervasive developmental disorder (PDD).  Following this diagnosis, vaccination with diphtheria toxoid (+) pertussis vaccine (unspecified) (+) tetanus toxoid and measles virus vaccine live (unspecified) were deferred.  Following the diagnosis, he "was put on trial of NYSTATIN".  It was reported that the patient was on "TMG. SuperNuthera (1/3 teaspoon 3 times a day), Taurine, NYSTATIN, cod liver oil, vitamin B12 injections" and was off of milk and wheat.  It was also reported that the patient was on folic acid, 0.8 mg, 2 times a day.  As of 30-NOV-2002, the patient underwent a third round of chelation, and as of 30-OCT-2003, the patient was on folic acid, 0.8 mg, 2 times a day.  As of 30-NOV-2002, the patient without improvement.  Additional treatment included methylcobamide, risperidone (RISPERDAL), donepezil hydrochloride (ARICEPT) and aripiprazole (ABILIFY).  The patient's vaccination history included: poliovirus vaccine inactivated (unspecified) given on 18-MAR-1999, 16-JUL-1999, and 18-JUL-2000; diphtheria toxoid (+) pertussis vaccine (unspecified) (tetanus toxoid given on 11-MAR-1999, 16-JUL-1999 and 17-DEC-1999; measles virus vaccine live (+) mumps virus vaccine live (+) rubella virus vaccine live (manufacturer unknown) given on 17-DEC-1999; varicella virus vaccine live given on 27-MAR-2000; and pneumococcal 4 6B 9V 14 18C 19F 23F conj vaccine (CRM197) (PREVNAR) given on 26-JUL-2001.  Information received on 12-SEP-2006 contained the following adverse experiences: otitis media (05-JUN-1999), fever (23-SEP-1999), papular rash (07-JAN-2000), a little adverse reaction to NYSTATIN (2000), nasophyringitis (September 1999), sinusitis (23-OCT-2000), viral upper respiratory infection (29-NOV-2000), conjunctivitis (05-MAY-2001), cough (05-MAY-2001), pharyngitis (02-OCT-2001), bronchitis (02-OCT-2001), rash (03-JAN-2002), gastroenteritis (04-MAR-2002), rhinitis (19-DEC-2002) rhinitis allergic (11-DEC-2003) and sleeping excessively with risperidone (RISPERDAL) (05?-MAR-2004).  Upon internal review autism and pervasive developmental disorder were determined to be other important medical events.  No further information is available.  All medical records will be provided upon request. (OMIC)