Age: 53.0
Sex: M
Vaccine: MMR, MMR
Symptoms: Back pain, Blood glucose normal, Blood test normal, Borrelia test negative, CSF immunoglobulin decreased
Clinical narrative: Information has been received from a nurse practitioner referring to a 53 year old male patient with hypertension. The patient had a history of viral meningitis 16 years ago (in August 2000). He had no drug reactions/allergies. On 26-MAY-2016 15:00, the patient was vaccinated with his possibly second dose of M-M-R II (lot # L026551 with expiration date 16-JUL-2017), subcutaneously (dose not reported). On an unknown date in May 2016 (reported as 1 month before admission), the patient experienced a viral illness with facial rash. But it was unknown if this happened before or after M-M-R II administration. On 29-JUN-2016 09:45, the patient reported significant pain at time of onset which had progressed to bilateral lower extremity numbness/paresthesias with decreased sensation perineal region and continued back pain along with bilateral left (BLE) weakness progressed during admission to paraplegia. On neuro exam he had BLE weakness that acutely progressed over one night to paraplegia with sensory loss in L4-S2 distribution and saddle anesthesis, loss of deep tendon reflex (DTRs) in the left, loss of rectal tone. The patient's cerebrospinal (CSF) did show albuminocytologic dissociation, and was otherwise also unremarkable. MRI lumbar spine: no contrast enhancement. On 29-JUN-2016, the patient went to the hospital and was diagnosed with "possible inflammatory acute transverse myelitis". Recently Magnetic resonance imaging (MRI) L spine on 3 Tesla MRI showed possible conus infarction vs acute transverse myelitis. Herpes simplex virus (HSV): negative, acyclovir was started initially then discontinued. CT abdomen/pelvis/chest didn't show malignancy. Lyme, cytomegalovirus (CMV) was negative. MRI brain was normal. MRI C spine: Mild multilevel degenerative changed result in no significant spinal canal or neural foraminal narrowing. Magnetic resonance angiography (MRA) spine: Curvilinear enhancing structure under the L4 pedicle noted which might represent a normal vein or might represent a draining vein related to a vascular malformation. Confirmation with spinal angiography was done and was normal. The patient was improving on DECADRON, so the doctor started SOLU-MEDROL 1 g daily for 4 days with monitoring his blood glucose (BG) and blood pressure (BP) very closely. "LP" was repeated and Oligoclonal Bands were negative. HTLV-1, herpes simplex virus (HSV), syphilis IGG were negative, Protein CS and Anti thrombin 3 were negative. Hypogammaglobulinemia, IgM: mild increased in CSF albumin. CSF index of IgG/albumin was normal. No oligoclonal CSF IgG bands was reported. The patient's BLE strength improved over the admission: 2/5 in iliopsoas with dysesthesia of saddle area. The patient underwent lumbar puncture in the hospital. Patient was recommended inpatient rehab. He would be discharged with a follow up with primary Care physician (PCP) and neurology. On 09-JUL-2016, at 15:27, blood glucose was 144 (unit not reported); at 21:13, 133 (unit not reported). On 10-JUL-2016, at 08:16, blood glucose was 110 (unit not reported); at 11:14, 90 (unit not reported); at 15:44, 108 (unit not reported). On 11-JUL-2016, the patient was discharged. The final diagnosis was possible inflammatory acute transverse myelitis. The secondary diagnosis was hypertension and constipation (since unknown date in 2016). The patient had good condition with intact cognitive. The patient was wheelchair bound. The patient's wife stated that possible inflammatory acute transverse myelitis was possibly results from M-M-R II. The reporter did not provide the causality. At the time of reporting, the outcome of possible inflammatory acute transverse myelitis was recovering. The outcome of other events was unknown. Upon internal review, possible inflammatory acute transverse myelitis was determined to be medically significant event. Additional information has been requested.