Age: 32.0
Sex: M
Vaccine: ANTH, ANTH
Symptoms: Nerve conduction studies abnormal, Pain, Pain in extremity, Paraesthesia, Peripheral swelling
Clinical narrative: This is a follow-up to a previously submitted VAERS report 585436-1. Patient is a 33-year-old M who was in his usual state of health on 26 Jun 2015, when he received his second anthrax vaccine in his right upper arm. He denies experiencing any unusual or prolonged redness, tenderness or swelling surrounding his vaccination site and denies experiencing symptoms consistent with an immediate hypersensitivity reaction, such an angioedema, hives/rashes, swelling of mouth and throat, cardiovascular, respiratory, and GI symptoms within first 4-8 hours of vaccine administration. On 26 Jun 2015, within 2 hours of vaccination receipt, patient noted generalized myalgias. He thought the aching could be related to vaccination and self-treated with Ibuprofen. On 9 Jul 2015, post-vaccination day (PVD) 13, patient awakened later than usual. When he got up, he experienced increased muscle pains as well as shooting pains down his extremities. He describes shooting pains as "lightning strikes". On 10 Jul 2015 (PVD 14), patient attempted to get an evaluation of his symptoms through Occupational Health, but was unable to schedule a same-day appointment. On 12 Jul 2015 (PVD 16), patient awoke with numbness of his thumb, pointer and middle fingers on his right hand, and in his pointer finger on his left hand, up to first knuckles. He went to hospital ER for evaluation. There his physical exam was normal except for "sensory abnormalities". He was diagnosed with Acute Dystonic Reaction. However, anaphylaxis, GBS, trauma, and myalgias related to statin were in the differential diagnoses. He was instructed to continue Ibuprofen for pain, but also prescribed Hydrocodone/acetaminophen 5/325 as needed for severe pain and to help sleep. He was prescribed Gabapentin 300 mg three times per day, but advised not to initiate until he was evaluated by Neurology. Patient had multiple serum lab tests run and was referred to Neurology. On 13 Jul 2015 (PVD 17), patient began first day of employment and notified his supervisor of his condition and his concern that it could be related to vaccine receipt. On 14 July (PVD 18), paperwork was submitted for patient to be evaluated by Neurology. On 15 July (PVD 19), patient was evaluated by Neurology. Per consult, patient's body aches had resolved and his numbness was improving and only affecting area on his thumbs. On physical exam, slight sensory decreased to a patch area on medial aspect of right thumb was noted and deep tendon reflexes (DTRs) were +2 throughout, and symmetrical. IMPRESSION: 32 y/o male with nonspecific resolved myalgia and now with ill-defined small patch area of finger paresthesia. No clear etiology. Differential diagnosis including vaccine related myalgia with lingering paresthesia distally. No sign of muscle disorder or neuropathy. No further diagnostics or treatment prescribed, but instructed to return if symptoms became worse. [PATIENT COMMENTS regarding above description of his pain resolution: Patient reported that the medicines prescribed had been helpful in reducing his body aches. Body aches were not as extreme and he was able to function. The numbness remained consistent.] On 22 Jul 2015 (PVD 25), patient awoke with numbness in both hands; not just in the fingers, but all the way to his wrists. He noticed weakness of his right hand as demonstrated by inability to hold coffee mug or open jars. He also experienced shooting pains throughout his extremities making movement difficult. Patient went to the ER for evaluation where he was evaluated by Dr. According to AHLTA entry, patient complained of numbness in fingers, but no weakness or physical pain. Physical exam was normal. Assessment: muscle aches, generalized: This 32 y/o male has had generalized muscle ache and numbness of all fingers, mostly tip of fingers for past 4 weeks. Seen in ED 12 July and neurologist on 15 July 2015 with ill-defined muscle ache, no obvious neurologic diagnosis. No diplopia or visual acuity changes. No hearing loss or tinnitus. No taste or smell sense changes. Normal speech and gait. No fever or chill. No headache. No URI symptoms. No muscle wasting or weakness. No saddle anesthesia or incontinence. Plan: Continue ibuprofen. Return to ER if worsens (muscle weakness or SOB). Nutritional consult for weight reduction and BP. Follow up with PCM. On 23 Jul 2015 (PVD 26), patient sought evaluation with PCM who immediately referred patient to a Neurologist. On 28 Jul 2015 (PVD 31), patient had appointment with the Neurologist, who transferred patient to the Emergency Department (ED) for evaluation, which included a lumbar puncture and nerve conduction velocity study. After an abnormal exam that was consistent with GBS, abnormal nerve conduction studies (NCS) and cerebral spinal fluid (CSF) profile showing albumin-cellular discrepancy, patient was admitted to hospital for IVIG treatment. He received 5 doses of IVIG and was discharged on 3 Aug 2015 to 1 month of "bed rest". He was verbally instructed to pace his activities at home. At the time of discharge, patient's symptoms of myalgias and shooting pains had decreased due to the medicines, paresthesias remained constant, and muscle weakness had improved. At home, patient required assistance with daily living in early Aug 2015 and slowly gained independence as he built up his strength through normal activity and household work. Pain medicines continued to keep pain at a manageable level. Paresthesias remained constant. On 10 Aug 2015 (PVD 45), patient woke up with numbness and weakness of his arms, and shooting pains throughout his extremities that prevented him from functioning. He was not able to lift his arms above approximately 33 degrees. He also experienced decreased strength in his legs making it difficult to walk independently. Patient was evaluated at hospital Emergency Department and admitted again for further evaluation and treatment. His nerve conduction velocity study revealed aggravation of demyelinating disease. Patient was treated with a 5 day course of IV steroids with noted improvement of his weakness. While he was in the hospital, he mostly used wheelchair to get around. Patient was discharged on 17 Aug 2015 and again prescribed 30 days "bed rest". At the time of discharge, he was unable to ambulate with a cane. He was prescribed a 30-day course of oral Prednisone 60 mg daily, along with Amlodipine 5mg one time daily, SYNTHROID .075mg one time daily, Atorvastatin 40mg one time daily, Acetaminophen 650mg/Tramadol 75mg three times daily, Gabapentin 300mg three times daily, Rabeone 10mg three times daily, Ca carbo/cholecalciferol 1250mg/10mg one time daily, and Quetiapine 12.5mg as needed for sleep. Patient was verbally advised to get back to a "normal" lifestyle as quickly as possible in order to regain strength, prevent unnecessary weight gain from the steroids, and that the bed/home rest order was just in case the body needed it for the entire month. [Patient reports that after his last hospitalization with IVIG treatment, he had a non-painful rash on his hands and feet that eventually peeled "like a burn". There was a question as to whether this rash was a reaction to the IVIG treatments, so when he was readmitted, he was treated with high dose steroids rather than IVIG.] His working diagnosis was CIDP. During the week following discharge, patient was aggressive in self-therapy, including walking, learning to climb and descend stairs and hills, and hand exercises such as squeezing a tennis ball with both hands. Patient's strength continued to improve. His strength in his legs had increased to about 50% of his baseline strength, and the strength in his upper extremities had returned to about 70-80% of his baseline. Toward the end of August, patient began to experience burning-type pains in the areas previously affected with paresthesias, as well as intermittent oversensitivity to light touch, especially in his fingers and hands. He also began to have intermittent shaking in his hands and feelings of intense swelling in his fingers, although no swelling actually occurred. During the week of 7 Sept 2015, patient reported his strength in his lower extremities had increased to about 60% of his baseline and his upper extremity strength had increased to about 80-90% of his baseline. With prolonged muscle use, he is still a "little shaky". He still experiences varied paresthesias. Patient was able to return to work part-time and as of 25 Oct 2015, he is working approximately 3 hours each afternoon. Patient returned to his Neurologist on 16 Sept 2015. Patient was prescribed an additional 30-day course of oral Prednisone 60mg daily. Additionally, they changed pain medications to improve his pain management. Medications include: Amlodipine 5mg one time daily, aluminum hydroxide 300mg two times daily, pregabalin 150mg two times daily, Ranitidine 150mg two times daily, SYNTHROID .075mg one time daily, Atorvastatin 40mg one time daily, Quetiapine 12.5mg as needed for sleep, as well as Prednisone 60mg daily. Patient plans to continue follow up with his Neurologist. He anticipates a slow taper off Prednisone after his 14 October Neurology appointment. Patient reports his pain has never gone away completely. The medicines help keep pain at a level where he is able to function. Mornings are rough when he first gets up after the meds have worn off through the night. In order to accommodate this, he is working afternoons. Now, he is having a significant amount of pain throughout his fingers.