Age: 18.0
Sex: M
Vaccine: VARCEL, VARCEL
Symptoms: Headache, Hypoaesthesia, Injury, Nausea, Pleocytosis
Clinical narrative: Information has been received from a registered nurse concerning an 18 year old male who on 10/30/03 male who on 10/30/03 was vaccinated with a dose of varicella virus vaccine. The nurse reported that the next day, on 10/31/03, the pt was hit in the head with a baseball. Later that day, he developed numbness of his right side, nausea, headache, and vomiting, but remained afebrile. The pt was hospitalized on 11/4/03 for testing. A computed axial tomography and MRI test were negative and cerebrospinal fluid was positive for pleocytosis with white blood cells at 256 and lymphocytes at 98 percent. Several days later, all symptoms resolved. It was noted that a prescription drug was not required. A product quality complaint was not involved. Follow information, including medical records, was received from the registered nurse which indicated that a headache developed that next morning, but the patient was able to play baseball. The patient was hit on the head by a baseball, but continued to play. On 11/4/03 the patient was admitted to the hospital with severe nausea and vomiting. Right paresthesia was also noted. The patient was afebrile. On 11/4/03 a CAT scan of the head was performed without contrast with the clinical findings of headache, vomiting, and hit with a baseball. Findings revealed that the ventricles were normal in size, shape and orientation. THe brain parenchyma showed normal attenuation. There was no intra-axial or extra-axial bleed or mass effect. There was no midline shift or brain herniation. The bony skull appeared unremarkable. The visualized paranasal sinuses were unremarkable. The impression was an unremarkable CAT scan of the head without IV contrast. On 11/6/03 an MRI of the brain was performed with and without contrast with the cllinical findings of severe headache and possible viral meningitis, and compared to the prior CAT scan examination of the head on 11/4/03. Findings revealed that the ventricles and cortical sulci appeared normal. Brain parenchyma showed normal signal intensity. There was no intra-axial or extra-axial mass or mass effect. There was no midline shift or brain herniation. Following the administration of intravenous contrast, there was no abnormal enhancing lesion. There was normal flow void in the distal vertebral, basilar, and distal internal carotid arteries. The corpus callosum, pituitary fossa, and the posterior fossa appeared normal. There was no abnormal signal intensity on the diffusion weighted images. There was minimal mucoperiosteal thickening involving the sphenoidal sinus consistent with sinus disease. There was no evidence of air fluid level. The impression indicated  that the brain was within normal limits without abnormal enhancement and there was minimal sphenoidal sinus disease. Laboratory tests (date unspecified) revealed increased protein at 86 and monocytes were 2 percent. It was noted that the patient was released on 11/5/03. Medical records also indicated that the patient started vomiting at 2:30 AM (date unspecified) and complained of a headache and was given ibuprofen and GatorAide. THe patient recovered on 11/7/03. See laboratory section for all other laboratory results.  Additional info has been requested. No further information is expected.