Sex: M
Vaccine: HEP
Symptoms: Diarrhoea, Gastrooesophageal reflux disease, Headache, Hyperbilirubinaemia, Influenza
Clinical narrative: Information has been received regarding a case in litigation concerning a minor male who was exposed to high levels of mercury from thimerosal through exposure to unspecified products. The alleged result was that the patient experienced serious and permanent neurological injuries and damages which included past and future mental, intellectual, developmental and neurological incapacity and associated learning disabilities, disorders and impairments. It was also alleged that the patient experienced cumulative mercury toxicity. Additional information has been received through medical records regarding this approximately three year old black male with no known allergies, who was born prematurely at 33 weeks gestation, who on unspecified dates was exposed to high levels of mercury from thimerosal through exposure to unspecified products. The patient's vaccination history included a dose of MMR II (lot#621430/1012E) given in the left arm on 14-Apr-1999, a dose of Orimune (Lot#456-271) on 14-Apr-1999, and a dose of Infanrix (Lot#890A2) given in the left thigh on 14-Apr-1999. Information received on 12-Sep-2006 contained the following adverse experiences: decreased temperature, watery stools and fussiness (18-Mar-1995), GERD (March 1995) which was being treated with Zantac and Propulsid, hospitalization for central apneas accompanied by desaturation and bradycardia (04-Apr-1995), tachycardia when asleep (04-Apr-1995), some asystoles up to four seconds (04-Apr-1995), apnea accompanied by bradycardia (04-07-1995) which was treated with low dose theophylinne, congestion (December 1996), general malaise and fever (30-Dec-1996), hospitalization for pneumonia (30-Dec-1996) which was treated with Zyrtec, mucus (23-Jul-2002), and chest pain (23-Jul-2002). Additional educational records were received on 06-Oct-2006. Teachers's comments regarding the patient for the 2005-2006 school year indicated that during the first quarter he continued to make steady progress meeting his individualized Education Program (IEP) goals, he worked hard and enjoyed small group interaction, though it took him a very long time to complete assignments. During the second quarter he made progress meeting his educational goals but he was spending an extended amount of time perfecting his handwriting which prevented him from completing his assignments in a reasonable amount of time. During the third quarter the patient had reportedly  done much better, he participated more and tried harder to increase his writing speed. During the fourth quarter he continued to make steady improvements, his reading fluency increased as well as his ability to answer questions about what was read, he also improved in math. Team meeting minutes from an IEP evaluation on 06-Apr-2000 indicated that the patient continued to exhibit communication delays. Meeting minutes from an IEP evaluation on 05-Jun-2000 indicated that the cognitive assessment did not support autism/PDD, and that the patient's disability should be changed from autism to mental retardation (evaluator bane and degree not specified). An IEP dated 11-Mar-2004 indicated that the patient's reading was at a 3.2 grade level for word recognition and a 2.7 grade level for comprehension, predicting fact/opinion, summarizing, generalizations. He was reported to be at a 2.9 grade level for computation and a 2.6 grade level for applications, performing addition, subtraction and word problems. It was noted that the patient was able to write base words, compound words, sentences, grammar, verbs, and nouns. The patient was able to copy from the board, his cognitive skills were "within average range", his speech was fluent, he respected himself;of, others, and property, he was physically healthy with good daily living skills and he had regular school attendance though tardiness was a problem. Additional medical records received on 25-Jan-2007 indicated that on 24-Feb-1995, the patient's birth-date, the patient was vaccinated with a first dose of hepatitis B virus vaccine rHBsAg (yeast). It was noted that the patient has two cousins with unspecified mental disabilities. In a follow up visit on 11-Apr-1996 it was noted that there was a suspected speech and language delay and that the patient was suspected to be at risk for developmental delay. As of 2005, treatment medications included Ritalin. These medical records also contained the following adverse experiences: hyperbilirubinemia (27-Feb-1995) which was treated with photo-therapy from 27-Feb-1995 to 01-Mar-1995, anemia (04-Apr-1995) which was treated with a blood transfusion, thrush (April 1995), cough (10-Jan-2005), cold (10-Jan-2005), nasal congestion (10-Jan-2005), viral illness (reported to be possible flu) (10-Jan-2005), narcolepsy (approximately 2002) treated with Provigil beginning in 2005, headaches (starting in 2004). Upon internal review, the patient's autism, mercury toxicity and apnea were determined to be other important medical events. No further information is available. All medical records are available upon request.