Age: 42.0
Sex: F
Vaccine: FLU3
Symptoms: Gait disturbance, Monoplegia, Muscular weakness, Pain in extremity, Viral infection
Clinical narrative: 43 y/o F requests vaccine causality eval of persistent lower extremity pain & weakness (bilat), w/ difficulty ambulating & onset of intermittent paralysis of LE's 10 days s/p receipt of AFLURIA inactivated IM (single dose, preservative-free) influenza vaccine on 28NOV11. No other vaccinated rec'vd on same day or w/in 30-days prior. (09FEB10) Missed step getting off bus "fell on knees & face-planted on ground." No LOC. Attributes onset of bilat LE pain to rucksacking during BT & AIT "carried a 97-lb ruck sack, wearing boots that were 2 sizes too big." Pt denies hx of osteopenia prior to age 40 on 28DEC09. Her entry WT was 113 lbs-a petite-framed F, s/p surgical menopause in 2000- only took 3 months HRT. (21APR10) Eval by Phys Therapy c/o bilat leg numbness & pain. (MAY 2010) Dx Bilat Tibial (Grade II), Femoral shaft  & 5th MT (L>R) Stress Fx's. A&P: Based on bone scan & physical sx >>> NO RUNNING PROFILE x 3 months. Upon graduation AIT, assigned to Broadcast Journalism. REC f/u at MC q4-6wk. (15JUL10) MC FAM MED c/o leg pain 1. Hx stress fx's- pain in legs below knees; 2. Screening exam: depression/mental or development disorders (NEG). (14DEC10, Phys Ther) c/o will no longer honor profile. (21DEC10) MC ORTHOPEDICS. Extension profile by FAM MED till eval by PODIATRY on (26JAN11) dx'd w/ Morton's Neuroma (L) foot. Steroid injections x 2 w/ cellulitis after 2nd injection; (04MAR11) rx'd w/ Levaquin; (06APR11) (L) SURGICAL RESECTION Neuroma (L) foot 3rd interspace; (23MAY11) f/u PODIATRY (L) foot swelling; (03JUN11) 8 wk f/u PODIATRY pt concerned she will not be able to deploy; PROFILE UPDATED PT AT OWN PACE; (27JUN11) REPEAT BONE SCAN: NO FEMORAL STRESS FX's / POSSIBLE STRESS vs. POST-TRAUMATIC CHANGES OF THE KNEE, ANKLES & FEET. (01JUL11) MC FAM MED f/u Bone Scan- NO FX / MINIMAL STRESS REACTION ONLY IN TIBIA. PCM explained to pt that her bones had healed. Pt worried that unit making her run too far too soon- made her run 4 miles yesterday & was to ruck w/ 60 lbs this morning. PCM told her if she does that, she will get new fx. Needs to PROGRESS SLOWLY. PCM wrote note detailing profile for unit. PCM presumptively rx'd w/ 50,000 IU Vit D weekly x 4, then monthly x 5. (01JUL11) pt's commander contacts PODIATRY re pt's physical limitations. (06JUL11) f/u PODIATRY 3 months s/p neuroma excision. Pt c/o minimal to no pain to (L) foot. (06JUL11) FAM MED Command needs more info re pt's profile & non-deployment status; (12JUL11) FAM MED Acute Visit PCM cc "I'm here to beg for an MEB." PCM told pt she does not meet criteria for DVT as she is improving & will gradually improve if she follows current profile. Pt states that command is not following profile & making her run/ruck march. PCM speaks w/ commander who says that is what they are doing & that pt does not want to do anything, even activities allowed on profile. They feel she is malingering to get out of deployment. (08AUG11) Ref. SPORTS MEDICINE-gave shin splint, rec stretching & strengthening exercises. Ref back to PODIATRY for orthotics. (30AUG11) FAM MED c/o anxiety/difficulty sleeping; Ref FAM MED PSYCH Resident, then to BEH Health for "Adjustment Disorder." (20OCT11) MED EVAL ORTH "her painful lower limbs interfere w/ successful performance of duty" MED REC. Pt has since been eval at length by WTU PCM's. Eval by multiple specialties, including MC Neurology, Pain Clinic, Physical Therapy, Podiatry, Orthopedics, Sports Medicine, Occupational Therapy & Behavioral Health. Neurological c/o's were unsubstantiated by MC Neuro after multiple diagnostics (see below), which were essentially negative & did not correlate w/ physical sx, leading to CONSENSUS DX of CONVERSION DISORDER. Second Neuro opinion requested by pt. Ref to another Neurosurgery who concurred. In July of 2010, she personally requested an evaluation by the healthcare center for possible vaccine causality of her sx. Medical Director (at the time) requested an approval by her PCM to begin this evaluation. At her initial interview, her reported sx were not c/w with GBS. She initially endorsed midway through her HC evaluation, she verbalized her opinion and concern that the content of aluminum contained in the vaccine may have contributed to her current illness and that her evaluation and documentation in her current record has not reflected an adequate investigation of that concern. The HC conducted a comprehensive investigation which included a 2-part, in-depth, face-to-face interview with the patient, a comprehensive review of her copious medical records, investigation of the vaccine excipients contained in the particular vaccine she received, which of note was preservative-free and did not contain any alum as an adjuvant, review of the Manufacturer's 2011-12 Package Insert, a VAERS search of the FDA/CDC Vaccine Adverse Events Reporting System database and a PUBMED search of the current medical literature. The pt was provided with a copy of the Manufacturer's 2011/12 Package Insert and a CDC Table of Vaccine Excipients. 1. Inquiry and counseling about medication administration and compliance (MEDICATION EDUCATION): Assessment: 1. History of skeletal trauma (stress fractures) and fall while getting off bus, followed by Primary Care and PCM(s) and unrelated to receipt of influenza vaccine. 2. Chronic multiple neurologic complaints (hypesthesia, chronic pain) a/w with difficulty ambulating, etiology undetermined, based on current evaluation, unrelated to receipt of influenza vaccine. Recommendations: 1. Based on patient's concern for aluminum toxicity, she should consider an evaluation with that focus. It should be noted that the literature recognizes aluminum toxicity in adults primarily with concomitant renal disease. The literature currently does not correlate the amounts of aluminum present in vaccines, particularly one vaccine, as a creditable source of toxicity. 2. Petition the Vaccine Injury Compensation Program. 3. Restrict future vaccination needs to a single vaccine at time. 4. Maintain current evaluation of HC database for follow-up if change in literature or signal recognition in VAERS database.