Age: 44.0
Sex: M
Vaccine: LYME
Symptoms: Influenza like illness, Joint stiffness, Muscle twitching, Musculoskeletal stiffness, Nausea
Clinical narrative: Report A0360261A describes fibromyalgia in a 45 year old male who received Lyme disease vaccine recombinant OspA (LYMErix). This report was received as part of the litigation proceedings, with forwarding of medical records. The vaccine provider submitted a report directly to VAERS (VAERS ID 168154). The medical history included seasonal allergies, allergic rhinitis, allergic conjunctivitis, dysphagia for solid food 1989, Schatzki's ring with esophageal stricture 1989, "severe" gastroesophageal reflux disorder 1992, hiatal hernia, esophagitis 1998, shoulder pain 1998, biceps tendinitis 1998, "muscle soreness throughout body" 1998, chronic neck pain, and "multiple" skin tags on the neck 1998. The vaccinee wore corrective eye. He smoked marijuana "once in a while." In June 1999, the vaccinee sustained a tick bite on his left leg. His primary physician reportedly said it was not disease and he did not receive antibiotic therapy at that time. Family history was significant for an unspecified esopageal disorder and myeloma in the vaccinee's father. Surgical history included multiple esophageal dilatations and removal of multiple skin tags. Concurrent medications included Prevacid, Claritin, Kenalog for the treatment of seasonal allergies, and "an abundance" of unspecified nutritional supplements. On 6/28/99 and 7/28/99, the vaccinee received his first (lot LY123B; expiry 2/17/00) and second (lot LY130B9; expiry 8/4/00) injections of LYMErix, respectively. On 2/11/02, in a Statement of Injuries, the vaccinee's attorney alleged that the vaccinee "suffers from joint pain and swelling throughout his entire body, specifically in his feet, knees, shoulders, back and neck. He also experiences fatigue, flu-like symptoms, headaches and gallbladder pain." The following information was obtained from medical records. The vaccinee presented to the vaccine provider on 9/2/99 with complaints of "sharp, throbbing" body pain, feverish feeling, loss of appetite, urinary frequency and burning, "dry and burning feeling in body," and dry mouth. The physician's assessments were "1. Myalgia-?fibromyalgia. 2. ?UTI." Urinalysis performed on 9/3/99 was negative, except for "trace' protein. The vaccinee returned to the vaccine provider on 9/9/99 with complaints of groin pain, chest burning and tightness, lightheadedness, "constant" right-sided rib pain, and dysphagia. On physical examination, "Multiple tender spots" were noted. The physician's assessment was "?fibromyalgia/GERD." He prescribed Elavil and referred the vaccinee to his gastroenterologist. Complete blood count (CBC) was within the reference range. Lyme antibody screen was negative. Please see Laboratory Data section. On 9/13/99, the vaccinee reported that he experienced shortness of breath, felt "very shaky," was not sleeping, had increasing polyuria, and had worsening right subcostal discomfort. The physician's assessment was "Atypical CP (chest pain), polyuria." On 9/22/99, the vaccinee reported that his symptoms began two days after he had drunk lake water. He reported that abdominal cramping and loose stools had begun on 8/30/99. The physician's assessment was "Cholecystitis? Giardiasis?" The vaccinee was referred to the gastroenterologist. A stool specimen was negative for Giardia antigen, ova, and parasites. On 9/16/99, the vaccinee was seen by his gastroenterologist for "right upper abdominal pain on a daily basis for the last nine days. The pain is present at a mild level of intensity for most of the day but is exacerbated by eating. He has had no nausea, no vomiting. The pain does not awaken him from sleep. He has had an evaluation with CBC, liver function tests, and had an ultrasound done on 9/14/99. The ultrasound raised the question of gallbladder disease but no stones were seen although there was a non-shadowing abnormality in the neck of the gallbladder suggesting a polyp. He has also been having groin pain, lightheadedness, and has been out of work for the past few days because of these symptoms. His GERD symptoms are also causing some problem. He has started to have dysphagia again for solids. He was taking Prevacid 30mg twice daily. He had one episode of food impaction about two weeks ago. He has never had this right upper quadrant in the past. Physical examination was unremarkable. "Assessment: Upper abdominal pain which is somewhat atypical for cholecystitis given its persistent nature. It was not clear whether his gallbladder is normal or abnormal on the ultrasound based on the report but no definite stones were seen." Oral cholecystogram on 10/2/99 "showed normal gallbladder function without any stones." The vaccinee returned to the gastroenterologist on 10/14/99. He reported dyspepsia over the past month. The physician wrote, "His symptoms are most consistent with acid peptic disease and not gallbladder disease because of their frequency and nature. He is still having some dysphagia for solids occasionally. He has stopped taking Prevacid and is taking Zantac and Pepcid AC on an as needed and has not noticed any dramatic change in his symptoms. Plan: Set up for upper endoscopy to look for evidence of recurrent stricture or acid peptic disease to explain his persistent symptoms." The vaccinee underwent repeat esophageal dilatation on 11/4/99. A duodenal specimen was negative for Giardia. On 11/30/99, the vaccinee was seen by the vaccine provider for a chief complaint of intermittent back stiffness, lower back pain for the past three or four days, and cramping in the groin area. He had no recollection of strain or injury. The physician's assessment was "?lumbar strain." He prescribed Flexeril. The back pain persisted on 12/6/99. The physician added Motrin to the Flexeril therapy. X-rays of the lumbosacral spine and pelvis were normal, as was serum protein electrophoresis. The back pain persisted on 12/22/99; the physician prescribed physical therapy. On 12/9/99, the vaccinee returned to the gastroenterologist because of "recurrence of his reflux symptoms with epigastric upper abdominal pain associated with regurgitation symptoms and dysphagia which is not relieved by using over-the-counter H2 blockers." The physician prescribed AcipHex. The physician noted, "He is interested in pursuing antireflux surgery since he has had so many problems with his symptoms." The vaccinee underwent repeat esophagela dilatation on 5/4/01, 6/29/01 and 8/31/01. On 3/20/00, the vaccinee came under the care of a new family physician. He reported his problem as "possible Lyme disease." The physician noted that "The vaccinee comes in with an array of symptoms occurring over the past one to four months. He notes that back in November. That lasted through into January. The pain was unexplained. He is having increased frequency of headaches since October. He has had some finger joint stiffness and arthritis for the past four to five weeks. He notes more pain and stiffness and it is worse in the morning hours. He has had more diffuse joint aches and pains in shoulder, hips, knees and ankles over the past three and one half weeks. He is also feeling a crampy pain like a groin pull right greater than left and the groin is somewhat sore to the touch. He denies neck stiffness. None of his joints have become red, hot, swollen or tender. He admits to some mild fatigue. It is not at all troublesome. He does not know of any tick bites. No family history of various types of arthritis including rheumatoid arthritis. No skin symptoms. He notes taking Osteo Bi-Flex for relief of arthritis symptoms, but stopped taking it "because it was not helping." on physical examination, there were "No visible abnormality of the upper extremity joints. He has full ROM of the hands, no apparent stiffness. No trigger fingers. No joint swelling. Exam of the lower back reveals some tenderness in the paraspinal muscles in the lumbar region. Otherwise normal. His assessment was "Diffuse migratory polyarthritis. I am most concerned for Lyme disease. The physician prescribed doxycycline 100mg twice dialy for 21 days. On 3/21/01, erythrocyte sedimentation rate was within the reference range; rheumatoid factor and antinuclear antibody titer were negative. Please see Laboratory Data section. The vaccinee remained under the care of this family physician until at least 11/3/01. The following additional signs/symptoms were reported during this time: twitching sensation of the eye lid and side of the eye, and "slight" shortness of breath with exertion and while in bed. During this time period, the physician initial improvement of symptoms while the vaccinee was taking doxycycline, but then symptoms were back the same as before. He continues to state  that he has migratory arthritis. He feels it jumps from one area to the next, "but he cannot state how he knows that the pain is actually jumping and that there is not more than one process going on." The vaccinee also reported that "he got some quick improvement that was sustained for a couple of weeks" after starting clarithromycin therapy, but "then started to get some of his symptoms back of migraotry arthritis." The vaccinee reported that a rheumatologist had prescribed Flexeril for the treatment of fibromyalgia. He also reported that an infectious disease specialist had prescribed minocycline; "He apparently felt better initially on the Minocycline and then again got worse." Testing for HLA-DR4 antigen was positive. The physician made a diagnosis of "Chronic arthritis and costrochondritis. Possibly related to an adverse reaction to the Lyme vaccine" on 3/14/01. The physician prescribed Ceftin 500mg twice daily for 20 days and Biaxin 500mg twice daily for three months. The physician referred the vaccinee to two rheumatologists, an infectious disease specialist, and a neurologist. On 4/26/00, the vaccinee was evaluated by a rheumatologist. The pt reported that in September 99, "he noted the onset of a syndrome hwich included lightheadedness, nausea, some back pain and stiffness, as well as a sense of tightness across his chest. Things may, in fact, had settled down until about two weeks ago when he developed these diffuse arthralgias involving a number of peripheral areas including his hands, wrist, shoulders, knees and feet. There was absolutely no objective swelling in any of these areas as observed by either the pt or a physician. He does say that there was some morning stiffness lasting up to two hours. With further questioning he reports that back in June he is sure he had a 'bulls-eye' lesion on his left leg. However, by his own description this lasted only for a couple of days, which would be unusual for a true ECM (erythema migrans chronicum) lesion. In any case, somewhere a few weeks ago, he was placed on a course of Doxycycline. After this he was placed on some Ceftin, which was started about two weeks ago. The vaccinee continues to complain of an assortment of symptoms including sore back and neck, blurred vision, twitching of his eyes, tingling of his fingers, generalized aching of joints and again lightheadedness. A complete musculoskeletal examination is entirely within normal limits. There simply are no objective abnormalities noted. He has some mild to moderate tenderness of some, but not all, of the so-called 'trigger points' described in pts with fibromyalgia. Impressions and disposition: Firstly, I'm not in any way convinced that this man has Lyme disease. Interestingly the lab is now back and, in fact, he has a negative western blot with only one band. I think this makes it highly unlikely that the problem her is Lyme. In any case, he ahs already been treated and retreated. The remainder of the lab, as you will note, is also exceedingly benign at this point, giving no support to a true systemic inflammatory process. I am more inclined to feel that he has a fibromyalgia syndrome, possibly triggered by a virus, possibly triggered by other factors such as stress, poor sleep pattern, etc." He prescribed Celebrex 100mg twice daily, and Norflex 100mg twice daily. The rheumatologist spoke to the vaccinee by telephone on 5/8/00. He told the vaccinee, "I doubt this is Lyme disease," to which the vaccinee responded, "I don't know how you can say that." The rheumatologist wrote, "I cannot convince the pt it is inappropriate to take chronic Ceftin." On 6/30/01, the vaccinee was evaluated by an infectious disease specialist "for possible Lyme disease." The vaccinee reported that "in June 99 he sustained a tick bite with what he thought was a bulls-eye like rash around it." The vaccinee reported that "In September, he experienced flu-like symptoms, nausea, and lightheadedness and went to see his doctor. He was tested for giardia and he was drinking lake water and that was negative. He also had gallbladder work up that was negative as well. In November through December of 99 he developed severe upper and lower back pain and multiple x-rays were negative. He had a serum immunoelectrophoresis to rule out myeloma since his dad had that disease and that was negative. December and February he continued to have flu symptoms and severe morning stiffness. In late February he developed joint pains throughout his body especially his hands. In March he saw a new physician who told him he most likely had Lyme disease and was placed on doxycycline 100mg twice daily for 21 days. After the first five days, he was feeling better but after two weeks, symptoms reappeared. In April he was placed on Ceftin 500mg twice daily for 21 days and again after five days felt great but after 15 days symptoms again were recurring. At that time, he went to see the rheumatologist who diagnosed him with fibromyalgia and suggested Elavil. In May he was placed on chronic Biaxin therapy which he was remained on which helped him initially but now he still feels only so-so with occasional good days and bad days. He also feels some stiffness and pain in his chest, especially in the costochondral joints. This leads him to feeling short of breath. He also has had light-headedness and nausea. The hands and the bottoms of his feet, lower back and neck also hurt. He often wakes up several times a night." Examination of the extremities "did not reveal any frank joint swelling or deformity. Review of his former laboratory tests show that all his Lyme serology is negative. He has nromal sedimentation rate and normal CBC and negative HLAB27. Impression: I told the pt that I strongly doubt that he had Lyme disease as unless that it is true that at the time of the rash he should have positive antibody testing. However, since the tick of Lyme disease can spread Ehrlichia, Babesia, and perhaps even a new pathogen we are not aware of , it is still possible that he was infected with something at the time of the tick bite. I think it is very important that he be able to sleep properly as that may improve all his other symptoms." Therefore, the physician prescribed Restroril 30mg at hour of sleep. He also told the vaccinee to stop taking Biaxin and to try minocycline 100mg twice daily. The physician repeated serologies for Ehrlichia, Babesia, and Lyme and measured liver function and vitamin B12 concentration. All results were negative. From 7/24/00 to at least 5/13/03, the vaccinee was evaluated by a psychiatrist who was "apparently a Lyme expert" on 7/24/00 for the treatment of Lyme disease. Additional sings/symptoms reported by the vaccinee included warts, numbness and tingling in the tailbone, and difficulty with word finding. The psychiatrist prescribed intravenous Rocephin for a 12 week course beginning on 10/26/00. "The pt at that time showed considerable improvement in some areas including joints, then beginning in the seventh week he experienced severe die-off reaction (Jarrich/Herxheimer Response). At that time Plaquenil 200mg twice daily was prescribed along with a continuation of antibiotic infusion therapy." The psychiatrist stated that he spoke to the vaccinee by telephone on 1/9/01. "Found the pt improved with more reduction of joint pain, but extremely sore rib cage and back going down to the spine. He still complained of equilibrium difficulties and he still has been unable actively participate in sports." The plan was to "Continue one month with IV Rocephin." During this time, absolute lymphocyte count was decreased. On 7/25/00, the third LYMErix injection was "declined" by the vaccinee. On 10/6/00, the pt was evaluated by a neurologist for a chief complaint of chronic arthralgias and headaches. The vaccinee reported that "He feels that he has chronic Lyme diseaseinfection and also was diagnosed with fibromyalgia." The vaccinee reported that he began to experience memory loss in early 2000. He also reported that there were "signs of ehrlichia" in his blood. On a questionnaire, the vaccinee indicated that he had experienced recent weight gain, fatigue, 'blurred or double vision," "hearing loss or ringing in the ears," chest pain or angina, palpitations, shortness of breath when walking, swelling in the feet or ankles, "painful bowel movements or constipation," "abdominal pain or heartburn," frequent urination, change in force of stream when urinating, incontinence or dribbling, sexual difficulty, testicular pain, joint pain, "joint stiffness or swelling," 'weakness of muscles or joints," muscle pain or cramps, back pain, difficulty walking, frequent or recurring headaches, lightheadedness or dizziness, numbness or tingling sensations, "memory loss or confusion," nervousness, depression, insomnia, "glandular or hormone problems," excessive thirst or urination, "hear or cold intolerance," and enlarged glands. The neurologist's impression was "The pt has a normal neurological examination with no clinical evidence of increased intracranial pressure, meningcal pressure, meningcal irritation, a focal deficit or central or peripheral nervous system disease. I am not able to find any congnitive deficits on a basic mental status screening. His symptoms were non-specific and protean. Many of them certainly are found on the long list of symptoms associated with chronic fatigue syndrome, depression, fibromyalgia and chronic Lyme disease. If this were Lyme disease, so far it would be seronegative Lyme disease. I really cannot state that any treatment for Lyme disease is indicated in this case." The results of cranial magnetic resonance imaging performed on 10/14/00 were interpreted as normal. Results of EMG and nerve conduction studies performed on 11/6/00 were interpreted as normal. On 10/13/00, the vaccinee was evaluated by a second rheumatologist. The vaccinee "presented today with concerns of persistent symptoms which have included lightheadedness, nausea, fatigue, some right arm pain and some memory difficulties which began in June 99 following a tick bite. He was later seen by an infectious disease specialist and at that time was noted to have a negative antibody screen for Lyme disease, normal liver function studies, and a mildly elevated ehrlichia titer. This was at the end of May. He was later seen by a psychiatrist who believed that his symptoms are compatible with chronic systemic Lyme disease and recommended that he undergo intravenous therapy with Ceftriaxone. He notes sleep abnormalities, waking up after 3-4 hours which occurred over the past year. He denies having tender trigger points on examination. He denies any history of Bell's palsy or cardiac arrhythmias. He denies joint swelling. He feels that he is progressively deteriorating after discontinuing antibiotic therapy." Musculoskeletal examination "was notable largely for some tenderness along the wrist extensor muscles of the distal forearm. He had pain with extension of his wrist against forced resistance. There was no weakness present." The physician stated, "I am uncertain as to the etiology of the vaccinee's symptoms. Although Lyme disease is in the realm of possibilities, it is striking that he has had repeatedly negative serologic studies despite the fact that this would be considered late in the course of illness. In addition, he did not have features to suggest Lyme disease from history. On the other hand, occasionally some patients may present somewhat atypically. Given his atypical presentation and his complete lack of response to numerous rounds of antibiotics. I thought it important to take a step back and consider alternative diagnoses. I did not recommend antibiotic at this point." CBC, thyroid function studies, liver function studies, and creatine phosphokinase concentration were within the reference ranges. Antinuclear antibody titer was negative. On 3/25/01, the vaccine provider submitted a report directly to VAERS (VAERS ID 168154). Under description of the adverse event9s), the physician wrote, "Lyme disease symptoms. Chronic arthritis. Significant joint and muscle pain. Lightheadedness, blurred vision, memory loss, slurred speech, sleep disorder." He indicated that the events began at 9:00 on 9/9/99, 43 days following the second injection of LYMErix . The physician indicated that these events "Resulted in permanent disability." On 12/5/01, the pt was evaluated by a second neurologist for a "a new headache disorder since surgery for reflux disease" in May 2001. The headaches were described as "a pressure sensation occipital in their maximum discomfort, steady, not associated with phonophobia, photophobia, or sonophobia. More recently, there has been throbbing quality to the headaches. He has no history of head injury per se. There is not significant family history of headaches. There are no clear provoking factors for headaches. There are not associated with visual obscurations or aura. No nausea or vomiting is noted. The pt has an extremely complex history. In the summer of 1999, he received a Lyme vaccine. He developed symptoms of arthritic complaints in his hands and feet, eigastric discomfort; his back bothered him, the he had vision loss, memory loss and lightheadedness." The vaccinee reported that he had been seen by a psychiatrist, "who is apparently a Lyme expert." The psychiatrist treated him with intravenous Rocephin for four months, "and his neurologic symptoms for the most part have resolved. He continues to complain of chronic arthritic complaints such as 'hurting all over' which he directly attributes to the Lyme vaccine. He has not been treated for chronic arthritis as best I can determine. He takes an abundance of nutritional supplements." The neurologic examination was normal. The neurologist's impression was "The pt has developed a chronic headache disorder. It seems unlikely that this is associated with reflux surgery beyond an association in time. It does have the qualities of migraine. There has been some nausea associated with the reflux symptoms. He has used Compazine with some benefit. He has been taking Advil three or four times a day. The pt clinically appears to be depressed, likely a reaction to the chronic illness, which he has now developed. He is having difficulty sleeping." The neurologist prescribed Paxil 10mg daily, increased to 20mg after two weeks. The physician also prescribed Celebrex for control of his arthritic complaints. The vaccinee returned to the second neurologist on 1/16/02. He was taking one or two tablets of Celebrex daily. "He reports no improvement in the painful dysesthesias in his feet." The vaccinee reported that he took Paxil "intermittently but not that much. It helps him when he needed to sleep. With respect to his headaches, they are 'fading.' They come and go every few days, lasting only an hour. They are mild." The physician told the pt to cut the Celebrex dose to one tablet per day for one week and ten stop it and see if there was any recrudescence of pain in his feet. He encouraged the vaccinee to take Paxil for one month. Following the reported onset of Lyme disease, the vaccinee experienced non-specific sT-T wave changes, atypical bronchitis, sinusitis, and increased concentrations of alanine aminotransferase. These events were not reported as adverse events due to vaccine administration, but were found during the course of review of the vaccinee's medical records. Therefore, they are not listed as adverse events. Information received on 4/3/02 indicated that the vaccinee was permanently disabled. As of 12/5/01, "his neurologic symptoms for the most part have resolved. He continues to complain of chronic arthritic complaints." Headaches were "fading" as of 1/16/02.depressed, likely a reaction to the chronic illness, which he has now developed. He is having difficulty sleeping." The neurologist prescribed Paxil 10mg daily, increased to 20mg after two weeks. The physician also prescribed Celebrex for control of his arthritic complaints. The vaccinee returned to the second neurologist on 1/16/02. He was taking one or two tablets of Celebrex daily. "He reports no improvement in the painful dysesthesias in his feet." The vaccinee reported that he took Paxil "intermittently but not that much. It helps him when he needed to sleep. With respect to his headaches, they are 'fading.' They come and go every few days, lasting only an hour. They are mild." The physician told the pt to cut the Celebrex dose to one tablet per day for one week and ten stop it and see if there was any recrudescence of pain in his feet. He encouraged the vaccinee to take Paxil for one month. Following the reported onset of Lyme disease, the vaccinee experienced non-specific sT-T wave changes, atypical bronchitis, sinusitis, and increased concentrations of alanine aminotransferase. These events were not reported as adverse events due to vaccine administration, but were found during the course of review of the vaccinee's medical records. Therefore, they are not listed as adverse events. Information received on 4/3/02 indicated that the vaccinee was permanently disabled. As of 12/5/01, "his neurologic symptoms for the most part have resolved. He continues to complain of chronic arthritic complaints." Headaches were "fading" as of 1/16/02.  Reported on 04/03/2003: "The most recent information, received on 03/25/2003, did not provide the outcomes of the reported events.  Information received 04/03/2002 indicated that the vaccinee was permanently disabled.  As of 12/05/2001, "his neurologic symptoms for the most part have resolved.  He contines to complain of chronic arthritic compaints."  Headaches were "fading" as of 01/16/2002. Reported on 06/04/2003: "Chronic headaches persisted as of 05/07/2003.  The outcomes of the fibromyalgia and gallbladder pain were not provided.   A 15-day follow up report received 07/29/2003 adds: The pt was evaluated by an ear, nose and throat specialist on 01/07/2003 for complaints of "sinus/ear congestion". At the time of the evaluation, the pt also reported "mild difficulty with instability but no true vertigo." This was described as "an instability sensation which comes and goes. He has been dealing with some balance issues prior because of Lyme vaccination, which appears to be on the mend". The pt reported that he "began having difficulty with his right ear and was placed on Guaifenesin and then two courses of oral steroids. He is now finishing a 10-day course of Ceftin and feels remarkably better. Occasional popping in the right ear. On physical examination, the physician noted "some exostoses of the ear canals, but drums were intact bilaterally." He also noted "Scarring in the tonsillar fossa." The physician wrote, "it appears that (the pt) is going in a good direction. It is difficult to say if he truly did have a sinus infection, but he is improving. With no middle ear pathology, I would say that he should do well, although to be on the safe side I did give him an extension of his Ceftin to eradicate any deep-seated underlying infection, which sometimes takes more than the 10-day course." The pt returned to his allergist on 06/12/2003 with "increased nasal and eye symptoms, sinus headache". The pt reported that he was taking cefuroxime for the treatment of Lyme disease. On physical examination, the allergist noted slightly red eyes, fluid behind both tympanic membranes, and edema of the nasal mucus membranes. He administered an injectin of triamcinolone acetonide and prescribed cetirizine (Zyrtec). Following the reported onset of Lyme disease, the pt experienced non-specific ST-T wave changes, atypical bronchitis, sinusitis, increased concentrations of alanine aminotransferase, hydrocele, Eustachian tube dysfunction, and trapezius strain. He also underwent laparscopic fundal plication for the treatment of gastroesophageal reflux disease and subsequent lysis of adhesions. These events were not reported as adverse events due to vaccine administration, but were found during the course of review of the pt's medical records. Therefore, they are not listed as adverse events. Info received on 04/03/2002 indicated that the pt was permanently disabled. The most recent info, received on 07/15/2003, did not provide the outcomes of the reported events. Info received on 06/30/2003, indicated that Lyme disease and sinus headache persisted as of 06/12/2003. A 15-day follow up report received 7/31/2003 adds: The most recent info, received on 07/25/2003, indicated that Lyme disease persisted as of 07/08/2003. A 15-day follow up report received 11/13/2003 adds: The most recent info received on 10/29/2003 did not provide the outcome of the reported events. Follow up on 12/12/03: "The most recent information received on 11/26/03 did not provide the outcome of the reported events.  Information received on 04/03/2002 indicated that the vaccine was permanently disabled.  Information received on 07/25/2003 indicated that Lyme disease persisted as of 07/08/2003." Follow up on 01/21/04: "The most recent information indicated that as of 07/16/03, the pt remained on short-term disability due to symptoms associated with Lyme disease. Information received on 04/03/02 indicated that the vaccinee was permanently disabled. Information received on 07/25/03 indicated that Lyme disease persisted as of 07/08/03." On 16 July 2003, the patient enrolled in physical therapy for treatment of status-post Lyme disease pain in the upper and lower extremities, difficulty with activities of daily living, decreased strength, and decreased indurance. On 03 September 2003, it was noted that the patient was progressing well, "tolerating low level conditioning excercises and stretching". Physical therapy was continued as of 16 September 2003. The patient was evaluated by a third neurologist between 18 June 2003 and 24 September 2003. On 18 June 2003 the patient reported low back pain, muscle spasms, burning and freezing sensation in feet, legs, forearms, and face, and intermittent weakness with difficulty walking. The neurologist's impression was that the patient might be suffering from post LYMErix vaccine neuropathy or myelopathy. On 02 September 2003, the patient's symptoms were worse with atriphy of his thighs. The patient reported that he had lost 10-15 pounds since his illness began. The neurologist's impression was chronic inflammatory demyelinating polyradiculopathy (CIDP). On 24 September 2003 it was noted that the patient was receiving care for CIDP, diagnosis confirmed by EMG/NC on 21 July 2003. Progressive weakness and sensory loss with more difficulty walking was noted. The neurologist recommended treatment with intravenous immunoglobulin (IVIg) and also noted that the patient migh also have chronic Lyme disease. A fourth neurologist evaluated the patient on 09 Oct 2003 who felt the patient had polyneuropathy with at least one demyelinating feature, with cognitive dysfunction being unable to work and an encephalopathy as well. The neurologist also recommended treatment with IVIG and that the patient discuss with his other physicians with regard to discontiuing chronic antibiotic therapy, as there is no clear indication that he has current Lyme disease.