Age: 18.0
Sex: F
Vaccine: MNQ, MNQ
Symptoms: Myasthenic syndrome, Nerve conduction studies, Occupational therapy, Pain, Pain in extremity
Clinical narrative: Initial report received on 9/29/05. This case was previously reported. An 18 year old female patient with a past history of asthma and seasonal allergies, received a first dose of Menactra, lot number U1657AA, on 7/25/05. The route and site of administration were not reported. 14 days later, the patient complained of difficulty going up a flight of stairs. Within two weeks of these symptoms, the patient complained of leg pain and had pins and needles in her feet. On 8/24/05, she had trouble standing and taking steps and started to fall down after taking two steps. She was seen by a private physician that day. At that time, she had a debilitating headache, vomiting, and had decreased reflexes in both her legs. Unspecified blood tests were ordered at that time. She was thought to have a viral syndrome and was advised to contact the physician if symptoms became worse. The notes from the clinic visit reportedly mentioned post-nasal drip in addition to weakness and paraesthesia. No neurological exam was documented. The absolute lymphocyte count was slightly low at 1187, and the labs were otherwise unremarkable. The patient's parent took her to an emergency room the following day, where it was noted that the patient's reflexes were absent. Unspecified blood work and a CAT scan were performed, but were reportedly negative. She as released from the emergency room and advised to rest. On 8/27/05, the patient was again seen in the emergency room because the pain in her legs was more intense and she could no longer stand up on her own. She had a headache associated iwth neck and back pain. She stated that she had progressive worsening in weakness in her bilateral lower extremities, which resulted in her inability to move her lower extremities for the past day. She had a fever prior to admission. She had a mild cough, which she attributed to her allergies, as well as photophobia and chronic post-nasal drip. It was reported that the patient had recently spent time working on a chicken farm and her symptoms of neck and back pain started after her return. A physical examination in the emergency room revealed weakness in the bilateral lower extremities with unusual sensation, headache, and neck rigidity. Her muscle power on the right lower extremity was 2.5 with decreased sensation. Encephalitis and viral meningitis initially were considered. Lumbar puncture showed a high protein count of 177 and a white blood cell count of 30 with predominant lymphocytes. An MRI of the brain was negative. Electrophysiological studies reportedly were consistent with GBS. The patient was admitted to the intensive care unit on 8/27/05 and because of progressive ascending weakness, was diagnosed with Guillain-Barre Syndrome. She was treated with two doses of IV immunoglobulins and late in the afternoon of 8/30/05 she became progressively more short of breath and hypoxic. She was unable to control her secretions and was electively intubated. She also had diminishing vital capacities of 1.7 in the morning and 1.2 late in the afternoon. At that point, she had lost her ability to swallow, talk, breathe, and move her limbs. The patient was worked up extensively and was treated empirically for encephalitis, but the subsequent consensus was Guillain-Barre with atypical features. Her medications while hospitalized included acetaminophen, ceftriaxone, Xopenex, morphine, Percocet, Protonix, Diprivan and Gabapentin. She was also treated with plasmaphoresis and had to be fed through a feeding tube. The patient developed oral candidiasis in the hospital. A copy of the patient's medical records, including all laboratory studies is on file and available upon request. It was noted that the patient was negative for N. meningitis types A, Y, and W-135, as well as EBV (EBV serology testing interpretation was suggestive of past Epstein-Barr Virus infection), CMV (CMV serology testing interpretation was suggestive of prior exposure to CMV), strep pneumoniae, strep B, H. influenzae, treponema, and facliparum. Stool cultures were negative (there was no explicit reference to campylobacter). A throat culture revealed moderate beta hemolytic group A strep at hospitalization day two, but none was isolated after day three. The patient spent three weeks in the hospital, she was released on 9/14/05 and admitted to a rehabilitation facility. At the time of this report, the patient had not recovered from these events.