Age: 1.28
Sex: M
Vaccine: MMR, DTAP, HIBV, IPV, MMR
Symptoms: Convulsion, Laboratory test abnormal, Mental retardation severity unspecified, Neurodevelopmental disorder, Psychomotor hyperactivity
Clinical narrative: Information has been received concerning a case in litigation, via medical records, concerning an approx 2 year old male with an unremarkable neonatal course and no known drug allergies with a family history of demyelinating process (brother)revealed via MRI who on 1/28/1989 was vaccinated with the first dose of MMR II 9lot 631641/0917J) was given on 9/3/1999. In approx Oct 1989, the pt was noted to have speech delay as he was no longer saying distinct words and could only be heard to utter jargon in a sing song manner. He was also noted to have stopped developing. In approx April 1990, a diagnosis of autism was made. on 5/10/1992 the pt was hospitalized in a pediatric ward for reactive air way disease, developmental delays and to rule out pervasive developmental delay. At that time, the pt was noted to have poor speech with a vocabulary of approx 15 words. He was evaluated by a developmental pediatrician who noted that the pt appeared to be showing very stereotypical behavior consistent with Pervasive developmental delay (PPD), in particular, autism, The physician noted that the pt had a severe verbal and non verbal communication disorder with some deviant social interactions. In additional, the pt had chromosomes which were also sent for fragile X, which were negative, High resolution chromosomes that were done revealed that the pt was a 46 xy normal male by chromosome appearance. The pt also had a normal EEG and audiological evaluation. A speech evaluation concluded that the pt had a severe speech delay pattern. Discharge diagnosis included PPD, probably moderate to severe mental retardation and reactive airway disease. On 7/10/1992, the pt was seen by a developmental pediatrician who confirmed a diagnosis of PPD, but was unclear of the specific etiology of the pts developmental difficulties. On 9/15/1992 and MRI of the brain was normal. On 3/19/2001, the pt developed a seizure disorder for which he was hospitalized. ON 3/20/01, a cranial CT scan was normal (no mass lesion and fluid space normal). The pt was also noted to have ADHD and neurobehavioral problems for which he was treated with multiple medications. As of 7/12/2001, the pt was becoming more violent, screaming all the time and hitting family members especially his mother, he had learned some single word slight vocabulary and spelling and numbers, but continued to converse in a single words at best and his verbal reasoning was rudimentary at best. The pt was currently taking lorazepam (Ativan) 4mg BID, divalproex NA (Depakote) 500 mg in the morning and clonidine 2 mg at night. Upon internal review, autism and moderate to severe mental retardation were determined to be an other important medical events (OMIC). Medical records received on 9/12/06 contained the following adverse experienced reactive airway disease requiring hospitalization. Ethmoideral and sphnoid sinus disease, revealed via cranial CT scan. No further information is available. All available medical records will be provided upon request.