Age: 65.0
Sex: M
Vaccine: FLUA3
Symptoms: Chest discomfort, Computerised tomogram normal, Discomfort, Electrocardiogram normal, Exercise tolerance decreased
Clinical narrative: This initial spontaneous case, was received from other non-health professional on 23-Oct-2017, concerns a 65-year-old elderly male patient, weighing 140 lbs and height of 66 inches. The patient underwent lensetomy on an unspecified date. Historical condition included dysinteria (dates not reported). Current condition included low blood pressure since an unspecified date. The patient was broad-shouldered, with a 30-inch waistline. The patient was fit, muscular and athletic. The patient's resting heart rate was 53 and did not have any known allergies. On 18-Aug-2017, the patient was administered with FLUAD (TIV) (dose: 0.5 ml, anatomical location: left arm, batch no: 178601, expiry date: Apr-2018 and route of administration: not reported). It was reported that, approximately 1 week after the vaccination, the patient suffered from a systemic attack and the patient was unsure of what system. On 26-Aug-2017 or on 27-Aug-2017, the patient went for swimming. After a few strokes, he had to stop as he felt soreness in his both elbows. Since that time, he had done little swimming and no push-ups at all. The patient also experienced tenderness. On an unspecified date, the patient went to gym to lift weights and he was unable to lift it from the rack. Bilateral arms triceps would twitch after lifting bars at the gym. He also tried doing push-up but he couldn't do more than 3, prior he could do many triceps before the flu shot. The patient also had soreness in his left arm. He recalled thinking that he was coming down with an illness of some kind. He experienced extreme weakness in bilateral arms and he could not exercise as he was not getting enough strength. In the following week he began to experience a number of physical maladies. From time to time his biceps would twitch in tandem and then they would be sore for few minutes or for few hours. As per patient, soreness caused mild discomfort but no pain, but an annoyance. The same thing would happen to his triceps, in tandem and subsequently the same phenomenon would appear in his forearms. From time to time, he found himself walking slowly, with mild discomfort in both groins. At the time of this report, he was able to function but not well and bilateral events had occurred several times over the course of the last 6-8 weeks (patient estimates it in dozens, occurring constantly, but at levels too slow to be perceived). In addition to these, the patient's hands were quick to fall asleep holding his cell phone, a book, or other small object. The patient stated that his arm fell asleep, but not in the usual way. He did not experience any constriction of blood flow but weakness and tingling. It used to happen any time and frequently happened at night (not every night but often). As the day passed by frequently felt tightening in his chest on the left side. In the past two or three weeks, he developed a strange sleeping pattern. Shortly after returning home from work, and eating, he "shut down" and fall asleep at 7:30 or 8 o'clock and used to awake 4 or 5 hours later, rested, but in a light sweat, with a mild headache or nausea, or all three. Again, he used to fall asleep at 4:30 or 5 AM, sleep restfully for 2 hours and awaken remarkably refreshed. His appetite has remained good throughout this ordeal, however in the absence of exercise he ate less and, consequently, his weight remained the same. About a month ago, the patient completely stopped taking alcohol otherwise he used to take moderate intake of alcohol. In the course of these past two months, a few things had been constant. Patient had experienced soreness at the site of the flu injection, and the weakness in his left arm had been more pronounced than his right. His elbows were both tender, not to the touch, but all on their own. On 30-Sep-2017, the patient found himself resting his left arm on the armrest, and then holding it in his right hand and he described it as it was like "fighting through the distress". On an unspecified date (reported as this Sunday), his left forearm began to ache and he struggled to maintain his composure. A day later the achiness had abated substantially. The patient was also diagnosed by carpal tunnel syndrome, but an EMG at Neurology has ruled it out, finding no nerve and muscle damage in his arms, wrists, and hands. On an unspecified date, the patient underwent EKG (electrocardiogram), a cat-scan (computed tomography), a lung x-ray and blood work which were all found negative (as reported). The patient did not have lyme disease or apparent autoimmune disease, but had been diagnosed with weakness caused by stress. He also experienced life-altering frustration, confusion, and fear. He had struggled to maintain the quality of his work, given up driving as he was fearful that his arms will fail him. The patient stated his social life had dwindled, healthy sex life had ground to a halt and pursuit of his hobbies had suffered. The patient was not given just a flu-shot, he was administered with an adjuvant intended to boost his immune system and he believed, the adjuvant was the cause of his distress. It was reported that, several weeks ago, one of his old friend and colleague reached out to shake his hand and when he extended it, they grasped his hand. He crumpled into his arms in pain. Since then, the patient reflexively recoil from an outstretched hand. On 20-Oct-2007, the patient began sauna sessions 2-3 twenty-minute sauna sessions daily, one in the morning before work, one or two in the evening depending on whether the patient swam at the gym. The first night after sauna, patient did not have night sweats or a sense of elevated fever. Before sauna visits, patient woke up every night with just under 100-101F fever and mild night sweats. Patient also noticed he no longer experienced mild nausea once starting sauna visits. Patient states he had no moisture on face or body after sauna initially, and felt the squalene adjuvant may have been preventing his body from sweating. After 1 week of sauna visits, sweat began to roll off face, and after 2 weeks of sauna visits, body is sweating normally. It was reported that, over past 2 days myalgia and heavy arms are improving and slept for 6 hours for the first time since the symptoms began. On an unspecified date, the patient recovered from the event "left forearm began to ache", myalgia and heavy arms. Outcome of other events were not reported. The reporter did not provided the seriousness assessment and considered the events as related to the influenza vaccine. The patient stated that he suspected the flu-shot as the origin of his ills. The patient was not given just a flu-shot, he was administered with an adjuvant intended to boost his immune system and he believed the adjuvant is the cause of his distress. The patient suggested the marketing of FLUAD be more informative that an adjuvant is contained in the vaccine and he believed consumers might misled. Patient believed he either had a bad reaction to FLUAD, got a bad batch, or was administered an overdose of vaccine. It was reported that as he was 65 years he would receive a double dose. Follow-up received on 08-Nov-2017: Added new events, 100-101 F fever, mild sweats, heavy arms, adverse event NOS, overdose. The outcome of the events myalgia and heavy arms were updated as recovering. Narrative amended accordingly.