Age: 36.0
Sex: M
Vaccine: LYME
Symptoms: Headache, Hiatus hernia, Hypoaesthesia, Immune system disorder, Influenza like illness
Clinical narrative: This case was reported by a lawyer and described the occurrence of joint pain in a male subject of unspecified age who was vaccinated with Lyme disease vaccine recombinant for prophylaxis. A physician or other health care professional has not verified this report. On an unspecified date the subject received unspecified dose of LYMErix (unknown). At an unspecified time after vaccination with LYMErix, the subject experienced joint pain, headaches, flu-like symptoms, possible memory loss, tingling, burning, numbness and decreased activities of daily life. It was reported that he experienced, among other things, rheumatologic, neurologic, and/or cognitive impairment of an autoimmune, immune-mediated, or other mechanism, all caused by vaccination with LYMErix, including, but not limited to, the above events. At the time of reporting, the outcome of the events were was unspecified. This information was received via a Statement of Injuries. Follow up information was received on 10/30/06 via medical records. Medical history included gastroesophageal reflux disease, bronchial asthma due to cadmium poisoning, gastritis, and helicobacter pylori infection. The subject was a 36 year old male who received LYMErix vaccinations on 5/10/99 and 6/17/99. Thirty days after the second vaccination, the subject developed musculoskeletal complaints including arthralgias. Treatment with prednisone was initiated, followed by a weight gain of approximately twenty pounds. In August 1999, the subject presented with dramatic improvement following a cortisone injection, but continued to experienced bilateral knee pain, hand pain, and finger stiffness. Synovitis of unknown etiology was diagnosed. The subject was reevaluated on 7/26/00 for persistent pain in multiple joints and burning in the tops of both knees, and noted that on some days he was unable to function. In December 2000, complaints included low back pain, which was attributed to trauma including a history of motor vehicle accident. Progress notes dated 1/19/01 indicated a diagnosis of Lyme titer induced autoimmune arthritis, treated with prednisone. In July 2002, the subject was receiving Biaxin and Suprax for treatment of Lyme disease variant, in addition to Os-Cal and Fosamax after being on prednisone for one and half years. On 3/31/03, he was evaluated for his anxiety and depression due to post-vaccination Lyme disease, osteoporosis "probably related to his years of steroids in treating this". Arthralgias were assessed to be stable at the time, and antibiotic therapy continued. On 4/5/05, the subject presented with a long history of axial neck pain exacerbated after the subject sustained a kick three to four months prior. Diagnosis included cervical spondylosis, treated with physical therapy and Voltaren. On 4/20/05, the subject presented for neurology evaluation with complaints of bilateral knee pain, arthralgia, numbness and tingling of the legs, dizziness, vertigo, and obsessive compulsive symptoms subsequent to administration of LYMErix vaccine. Examination revealed reduced sensation along the anterolateral thighs and knees, mild nystagmus of the later gaze, hypoactive knee jerks, Romberg sign, tandem imbalance, and generally normal cognition. A skin punch biopsy on 6/6/05 showed significantly reduced epidermal nerve fiber density indicative of small fiber neuropathy. The subject was diagnosed with a syndrome of gliadin-autoantibody associated painful small fiber neuropathy, vestibulopathy, celiac disease, and arthralgia triggered by LYMErix vaccination. Treatment with IV immunoglobulin was initiated, followed by improvement of vertigo, arthralgia and neuropathic pain. On 10/6/05, the subject was evaluated for possible celiac sprue. The gastroenterologist noted a history of Lyme disease like illness secondary to LYMErix, in addition to osteopenia, intermittent dyspepsia, and migraines. A skin punch biopsy in January 2006 showed normal ENF density. Based upon follow up information, this case was assessed to be medically significant (OMIC). During the subject's disease course, attempted treatment included Neurontin, Indocin, Vioxx, Diclofenac, Bextra, Mobic, Ibuprofen, Celebrex, glucosamine chondroitin, and Plaquenil. The subject was also evaluated for palpitations and premature ventricular contractions (August 2002), chronic hepatitis of unknown etiology (date of diagnosis unknown), and hiatal hernia. On 3/31/03,. he was evaluated for mild hypertension and osteoporosis "probably related to his years of steroids in treating this", hyperlipidemia, and obesity. These were considered to be incidental findings upon review of medical records.