Age: 63.0
Sex: M
Vaccine: DTAP, VARZOS
Symptoms: Neurological examination normal, Neuropathy peripheral, Nuclear magnetic resonance imaging normal, Paraesthesia, Pruritus
Clinical narrative: Information has been received from a 64 year old male dentist concerning himself who in March 2008, was vaccinated with ZOSTAVAX (Merck).  Since the vaccination he experienced periodic burning and tingling sensations in the left shoulder which radiated into his neck and into the lower border of his left mandible.  These were lasting only a few seconds and were followed by itching of the neck and jaw.  Over the past eight to ten weeks symptoms have increased both in frequency and intensity.  A course of therapy with VALTREX had no effect.  However a course of therapy with steroids caused the symptoms to temporarily disappear completely.  Follow-up information was received from a physician via medical records on 14-OCT-2008 concerning a 64 year old male divorced dentist with Penicillin and MARCAINE allergies and a history of shoulder injuries from skiing and constipation from tramadol.  The patient also had a stroke-like episode in 2004.  He described this as an episode of disorientation, where he repeatedly asked the same questions.  He was given TPA and was admitted to another hospital.  The neurologist thought this appeared to be an episode of transient global amnesia (TGA in retrospect).  The patient drinks alcohol in moderation.  He was a previous smoker, but has quit now.  The patient's father died at age 86 with Parkinson disease and his mother at age 79 also with Parkinson disease.  On 07-JUN-2007 the patient was vaccinated subcutaneously in the left deltoid with a first 0.5 ml dose of ZOSTAVAX (Merck) (Lot # 656858/0356U).  On the same day, he also received Tdap.  The patient also received a completed series of hepatitis B vaccine (the third dose was given on 01-JAN-1996).  The patient reported that the symptoms of tingling and numbness in his left shoulder, arm and hand started slowly "last summer" (in approximately July 2007) while he was on vacation.  These symptoms continued to occur and to increase slightly during the fall and winter of 2007 to 2008.  The patient described the symptoms as a sensation of paresthesia (tingling) that affected thumbs and index and middle fingers.  The paresthesias always lasted under a minute (usually about 10-15 seconds) and then resolved completely without any residual sequelae.  The symptoms occurred about five to six times a day.  He also had intermittent itching that was not present persistently.  The patient had not noted any problems with his vision and did not experience any paresthesias involving the other extremities.  There were also no problems with bladder or bowel or with his gait (apart from previous constipation from tramadol).  "About six weeks ago", on approximately 28-JAN-2008 a MRI  of the cervical spine was done and the results were normal.  On 03-MAR-2008 the patient was seen by a neurologist and had a normal neurological examination.  Since the patient had shoulder injuries from skiing, the neurologist thought that it was possible that the patient might have a subtle sensory cervical radiculopathy.  For this reason, an electromyogram was performed on 30-APR-2008 and the results revealed mild carpal tunnel syndrome on the right and mild-to-moderate carpal tunnel syndrome on the left with mild ulnar neuropathies at the elbows.  The patient was diagnosed with mild carpal tunnel syndrome (bilateral with mild ulnar neuropathies).  But the neurologist thought that these would not explain the patient's symptoms of paresthesias over the left side of his chest.  The neurologist did consider the possibility of zoster without the rash (sine abruption).  However, it was low on the differential.  Paresthesias such as itching can also be a side effect of medications such as opioids or tramadol.  The neurologist thought that the carpal tunnel syndrome and ulnar neuropathies did not need to be pursued any further unless they worsen in the future.  The patient reported that "over the past week to ten days", on approximately 15-AUG-2008, his symptoms had also included pressure in the shoulder area that felt like his shoulder was being squeezed from periods of up to ten minutes.  This had, on occasion, been moderately painful, but had not been painful enough to keep him from working.  At the time of the report, 14-OCT-2008, the patient had not recovered from the events.  Additional information has been requested.