Age: 46.0
Sex: F
Vaccine: HEP, IPV
Symptoms: Fatigue, Gait disturbance, Gliosis, Lumbar puncture, Malaise
Clinical narrative: First injection of Engerix B: 04/17/02. Second injection: 05/16/02. Demyelinating event:07/04. Emergency room visit. CT scan and MRI with contrast. Diagnosis: gliosis associated with demyelinating events/disease. Symptoms: extreme fatigue, difficulty walking, severe cognitive impairment, chronic fatigue, night sweats, anorexia, blurry vision, balance difficulties, muscle weakness. Acutely ill and incapacitated for 3 months. Tested for Brucellosis, Japanese Encephalitis. Slow return to health and symptoms decreased. Third injection: 4/14/06. Symptoms return within a month. Acutely ill for 6 weeks. Tested for Lupus, Fibromyalgia, and Lymes disease by pcp. Referred for work-up by either rheumatologist or neurologist. Health declines. Extreme exhaustion. First diagnosis: CADISIL. Tests: MRI, spinal tap. MRI reveals no increase of gliosis from 2004. Spinal tap reveals oligoclonal bands in csf, evidence of a demyelinating event. Diagnosis: Atypical multiple sclerosis. Continued treatment with Dr. at Multiple Sclerosis clinic. Most recent MRI: 08/03/09. Assessment: No change from 2004. Possible "brain insult" from vaccine that triggered auto-immune response.  8/20/09 ER records received DOS 7/19/04. Assessment: Altered sensation with white matter disease, question ischemic versus post-traumatic. Patient presents with concerns about exposure to Asian variation of encephalitis while recently traveling in Mongolia.  Experienced strange sensations, fatigue, disorientation, sensation of 'some realism', waves of "awfulness". Fever, sweats, rhinorrhea, restlessness. Presents with headache. Also concerned that she may have had a seizure after a recent motor vehicle collision. Discharged in stable condition.  8/24/09 Received Neuro consult of 1/506-8/3/09. FINAL DX: multiple sclerosis; demyelinating disease; pre-diabetes mellitus Records reveal patient experienced viral illness during foreign travel in 2004 w/extreme fatigue, wt loss, ringing in ears, constipation, balance disorder, crying & sneezing spells which slowly resolved until spring 2006 when developed anorexia, difficulty walking, heat intolerance after additional foreign travel.  Improved slowly then developed extreme fatigue again, leg weakness & falls. Tx w/multiple meds including IV steroids but continued to decline.  Meds were discontinued & patient improved.  Dermatology consult of 3/7/0-5/16/08reveals patient received Botox & restylane treatment & had vasovagal reaction.  9/3/09 Received PCP medical records reveal when patient seen 8/3/04 that symptoms began abruptly on 7/5/04 while on foreign travel & spouse had similar symptoms that resolved.  Patient initially improved but then s/s recurred: nightsweats, HA, possible hallucinations, lack of energy, difficulty walking, backache, constipation, trouble concentrating, loss of appetite, weight loss, flu like symptoms, fatigue, dermatitis rash from 2002 aggravated.  Neuro consult done 7/19/04 final dx: altered sensation w/white matter disease, question ischemic vs post-traumatic.   2nd Neuro consult done 8/17/04 w/final dx: possible seizure disorder; possible toxic delirium related to Ambien; hx of head trauma/concussions; subclinical gliosis.