Age: 0.48
Sex: M
Vaccine: DTAP, HIBV, PNC, RV5
Symptoms: Epstein-Barr virus antibody negative, Escherichia urinary tract infection, Full blood count, Herpes simplex serology negative, Hypotonia
Clinical narrative: Information was extracted from his discharge summary on 8/31/08: "7 month old boy, previously healthy who had diarrheal illness 1 week ago...found to have poor tone in lower extremity on 8/28. He was slumped over and unable to sit up. Subsequently transferred from one hospital to another medical center where CBC, renal, Head CT, LP were done. At the ED, he was noted to have weak cry, with normal neck strength and negative bulbar signs. No nystagmus. "CT head was normal, MRI brain and spine revealed normal brain, spine with evidence of myelitis. CSF cultures with no growth. Viral PCR was negative for enterovirus, EBV, CMB and HSV, with HHV-6 and arbovirus still pending at time of discharge. CSF IgG, albumin, oligoclonal bands pending at discharge." "Patient discharge diagnosis not hypotonia, but rather acute transverse myelitis. At this point, considered idiopathic/post-viral as studies to date have not identified a specific cause. Patient treated with IV SOLUMEDROL...to continue slow taper oral prednisone over next two weeks. He was diagnosed home with no restrictions and to follow up in Neurology clinic with Dr. From D/C summary with d/c date of 9/9/08: Admitted 9/1/08. "In ED, patients RR noted to be in the 90's with belly breathing and retractions. He was able to maintain oxygen saturations. He was given MOTRIN in the ED with resolution of fever. Neuro was consulted in the ED and found current respiratory symptoms, unlikely to be due to thoracic transverse myelitis. During hospital course, episodes of desaturation during sleep treated with blow-by O2. Desaturations to 95%. CXR negative for infiltrate and repeat respiratory PCR panel negative. Pulmonary consulted and recommended trail of albuterol, suctioning and repeat CSR (which showed minimal sub segmental atelectasis within media right base). CPT and suctioning were also initiated. The night prior to discharge, patient had one episode of desaturation, per report approximately 86-89% during sleep with self resolved...Pulmonary cleared patient to be discharged home. Patient d/c'd with albuterol PRN, bulb suctioning and education to keep head of bed elevated. Neurogenic bladder -renal ultrasound showed urolethial thickening and urology consulted. VCUG (9/2) showed left sided reflux-grade 1-2. F/U with renal US in 2-3 weeks and F/U with urology after renal US. Ortho-decreased ossification of femoral head noted bilaterally on KUB. Hip US showed no developmental dysplasia of the hips with delayed ossification center of femoral head, unknown etiology (9/3). Will repeat US in 2-3 months." Pt was discharged on 9/9/08 with follow ups scheduled for Dr. (pediatrician), Dr. (neurologist), Dr. (urologist) and Dr. (rehab-med).  7/31/09 Hospital records received DOS inpatient 9/1/08 to 9/9/08 with follow-up visits to 3/30/09. Assessment: Respiratory distress. Patient previously hospitalized for tranverse myelitis, oxygen desaturation, neurogenic bladder, febrile illness. Now noted at home to have fever and tachypnea, brought to ER and readmitted. Increased fussiness. Respiratory rate in the 90's with belly breathing and retractions. Nasal congestion, cough. Hypotonia trunk. Urinary tract infection - E. Coli. Neurogenic bowel.   ICD-9 Codes: 599.0  341.22  596.54  593.70  466.19  079.99  733.99  564.00   786.09   Follow-up: After reviewing publication on Transverse Myelitis, we have noted the following information: "Symptoms of transverse myelitis include a loss of spinal cord function over several hours to several weeks. What usually begins as a sudden onset of lower back pain, muscle weakness, or abnormal sensation in the toes and feet can rapidly progress to more severe symptoms, including paralysis, urinary retention, and loss of bowel control." "Transverse myelitis may be either acute (developing over hours to several days) or subacute (developing over 1 to 2 weeks). Initial symptoms usually include localized lower back pain, sudden paresthesias (abnormal sensation such as burning, tickling, pricking, or tingling) in the legs, sensory loss, and paraparesis (partial paralysis of the legs). Paraparesis often progress to paraplegia (paralysis of the legs and lower part of the trunk). Urinary bladder and bowel dysfunction is common." "Bladder and bowel problems may involve increased frequency of the urge to urinate or have bowel movements, incontinence, difficulty voiding, the sensation of incomplete evacuation, and constipation." On August 16/17, 2008, pt began approximately a week long bout of diarrhea, lasting from Saturday/Sunday till Thursday/Friday. A call to the pediatricians' office was made and they recommended that as long as he did not have a fever, was able to continue taking fluids and baby food, and was not vomiting, that he probably had a stomach virus and we were to continue what we were doing and bring him if his condition changed. Considering the above information and given his age at the time (7 months) along with his inability to effectively communicate, we are submitting that the Adverse Event Onset was August 16 or 17, 2008.