Age: 0.2
Sex: F
Vaccine: DTAP, HBHEPB, IPV, RV
Symptoms: Encephalopathy, Sleep disorder
Clinical narrative: Information has been received from a physician concerning a 9-week old female patient  who was the product of a pregnancy complicated by gestational diabetes and hyperthyroidism, who on 04/26/99 was vaccinated with the first dose of haemophilus b conjugate vaccine (+) hepatitis b vaccine recombinant IM in the right thigh (lot # 629304/1616H). Concomitant vaccination that same day included the first dose of each poliovirus (IPOL) IM in the right thigh(lot number N0826), alumium potassium sulfate (+) diphtheria  toxoid (+) pertussis vaccine (Tripedia) IM in the left thigh (lot number 0962260, also reported as 0967760), and rotovirus vaccine (Rotashield) PO (lot number 4988106). On 5/6/99 the child was found in her crib to be cold and blue, with frothy material noted from her mouth. It was also reported that her mother found her unconscious, not breathing and bleeding from her mouth. The child's mother instituted CPR and an emergency team was notified. The patient was hospitalized and regained  spontanteous  respirations following arrival. The child was fluid resusciated, a blood culture was drawn, and she was treated with ceftriaxone. She was then incubated and transferred to another hospital. The child required bagging and fluid boluses while en route to the second hospital. At the time of transfer, a physical examination was significant for an afebrile child with stable vital signsa. The patient was noted to be unresponsive to visual stimuli and did not respond to visual threat. Additional findings included transmitted upper airway sounds on auscultation of the lungs, as well as decreased tone in the lower extremities bilaterally. The child was noted to have equal patellar reflexes, not noted to track,and had no grasp of the upper extremities. Upon admission to the ICU, child was loaded with Phenobarbital and maintained on this medication. While in ICU, the child was incubated and ventilated. An initial x-ray demonstrated bilateral infiltrates, which subsequently cleared. The child was ventilated using minimal support until 05/10/99, when she was extubated to room air. By 05/12/99, she was tolerating room air well.The patient continued to be treated with ceftriaxone, as well as acyclovir, and all cultures were negative PCR analysis for herpes was negative. The child was given dopamine for blood pressure support, however she was weaned off this upon transfer to the floor, at which time she was also off antibiotics and antiviral medicvations. The child had three CT scans, which demonstratrated a worsening picture of cerebral edema and poor differentiation between gray and white matter. The patient was noted to have a good suck and gage reflux, however seemed to be "obviously disabled in this area." The child was found to be anemic and started on iron therapy. Opthalmologist and initial CT scans were  within normal limits. There was no evidence of abuse. While on the floor, she received a "VER while on V7." Other events included weaning of the patient's phenobarbital level every four days. Results of studies "while on V7 demonstrated no activity on VER." The patient had a normal EKG and patient still did not have any respiratory abnormalities. On 05/15/99, the child was discharge in stable condition with a diagnosis of anoxic brain injury, cortical blindness, and a near SIDS event. Discharge medication included phenobarbital wean, ferrous sulfate and Enfamil with iron PO. Follow-up with a neurology clinic was arranged. On 03/31/99, the child had a mild cold that lasted a week. she was noted to have poor vision, spasticity, and decreased cognitive response secondary to seizure. On 06/28/99, the patient's hemoglobin was 12.5 On 08/31/99, a physical examination revealed that patient's eyes "focused briefly and she had a floppy head.' Follow-up information indicated that the patient's performances on mental and motor examination on 10/11/99 was significantly delayed. The child quality of response, attention span, and interest level were noted to be immature. A neuroloigical examination  was abnormal. The child was fussy, then settled down. she had a tendency to arch, had frequent tongue thrusts, strong asymmetrical tonic neck reflex, responded and seemed to localize sounds, tried to reach and grasp for objects, had inconcistent visual skills, and occassionally seeemed to regard objects. Her deep tendon relexes were brisk, no clonus was present, and she had good range of motion. it was reported that the child had a history of seizures treated with clonazepam (Klonopin), and a recent URI. After examination, the child was felt to have static encephalopathy following near SIDS, an abnormal neurodevelopmentexams with global delays, and inconsistent visual skills. She was noted to have some progress in motor skills and early language, and was very responsive to auditory stimuli. The patient was sceduled for a follow-up appointment on 02/21/00. Additional followup information indicated that the patient had no pulse and was givcen CPR wirth thbe return of respiration and heart beat. In 06/00, the patient was given a physical exam (no details were provided). Follow-up information received from a physician indicated that the status of the patient was unchanged on 9/11/02. The reporter considered the events to be immediately life-threatening and disabling.  No further information is available. Additional information is not expected. This case is closed. A 15-day follow up report received 10/24/2003 adds: Follow-up info received on 10/06/2003 indicated that the pt subsequently was diagnosed with mixed spastic quadriplegic cerebral palsy, sleep disorder, oral motor dysphagia, poor weight gain and bowel/bladder incontinence. On 07/31/2003 the pt was seen by a pediatric physiatrist at 4 years 5 months old for a neurodevelopmental follow-up. At this time, her chief complaint was sleep issues and recommendations for 2004-2005 school placement. It was reported that she has received 175 hyperbaric oxygen treatments and she has one more session in the fall of 2003. Her mother was seeing no motor improvement, but has seen speech improvements. Her body systems were reviewed and the assessment included: no changes in vision, she was last seen in May 2003 and respiratory - developed a cold 07/30/2003 and has a low grade fever. She was still a fussy eater and she curls her right hand in and bears down to give a signal for BM. Had ortho rehab on 05/03/2003 and was fitted for new AFO's last week. Her skin was yellow, sometimes looks jaundiced; LFT's okay and CBC was negative. She has an ear infection after every cold and completed antibiotics at the end of June 2003, questioning if she needs tubes. In April 2003 ear surgery was performed for removal of a recurrent cyst on her earlobe. Neurologically, no specific seizure, occasional blank stares noted and the Nov 2001 sleep study showed low level activity; no medications were recommended. Her cardiovascular, genitourinary, psychiatric, endocrine, hematologic, immunologic and pain systems were negative. It was reported that she does not sleep much at all, is up 3-4 times a night and wants constant attention. Physical examination included: weight 31.2 lbs (10th percentile), height is 40 inches (25th percentile), WHZ is 10th percentile, OFC 45.5 cm and temperature 98.6. She was alert, NAD, her skin was yellowish color, variable; HEENT - non-icteric sclera, and mild drooling, she tracks and positive nystagmus was noted. Decreased adduct thumbs with wrist flexed. Legs full PROM and spine straight. Extensor posturing with standing and reciprocal gait with upper body supported. Genu recurvatum bilaterally and up on toes bilaterally (without AFO's on). Balance poor alone. Cerebellar - Choreoathetoid movement of bilateral upper extremities. Her cranial nerves II-XII were not assessed and her motor strength was difficult to assess secondary to her being uncooperative. She had increased motor tone in all four extremities, but variable. Extensor tone was noted in the lower extremities and flex in the upper. Significant tone was noted at the ankles, the right greater than than left. It was difficult to upper extremity deep tendon reflexes, patellar 3+ bilaterally. Neurodevelopmentally, she was non-verbal and had difficulty isolating index finger for pointing. Her chest and genitalia were not examined. She was on trihexyphenidyl for athetoid movements and this was discontinued in June 2003 after 4 months because no change was noted. Progress developmentally included improved hand-eye coordination, eating third-stage baby food and hasn't progressed beyond that; she has difficulty with meats. She says "mama", "more" and "up" and gestures for needs and wants. The plan was to refer the pt to a sleep study group and monitor her weight and oral intake. A dermatology consult considered for her yellowish skin; her mom reported that her LFT's have been within normal limits and she does not eat excessive carotene. Monitor her movement disorder and possibly try other medications in the future (she failed the trihexyphenidyl hydrochloride (Artane) test in the past). Return to the clinic in one year. The reporter considered the pt's apnea, seizures, cortical blindness, anoxic brain injury and cerebral edema to be immediately life-threatening, disabling and other important medical events. Follow-up info received on 10/06/2003 included the following adverse experiences: upper respiratory infection (1999); mild cold (1999); ear infection (onset unknown), cold (onset unknown), low grade fever (onset unknown) and cyst on earlobe (onset unknown). Additional info has been requested.