Age: 44.0
Sex: F
Vaccine: DT
Symptoms: Myalgia, Palpitations, Paraesthesia, Rash, Tinnitus
Clinical narrative: Initial report received on 23/Feb/2006 from the patient.  A 45-year-old female patient with a history of allergies to mold and a recent wound received from scraping her arm on a rusty nail, had received an injection of DECAVAC, manufacturer given, lot number U1587AA, in the right deltoid on 03/Dec/2005.  Two days later, she experienced numbness in the left foot and leg.  Approximately one to one and a half arm.  The left leg was "sore to touch".  At that time she also complained of a headache and "head fog".  The patient was seen by a neurologist and an MRI was completed.  The date and results of the MRI were not reported.  It was not reported if the patient recovered from these events at the time of this report.  Follow-up information received on 30/Jun/2006.  Per the reporter, the patient had not been seen at their facility and that the request for follow-up information must have sent to the wrong facility.  No further information is expected.  Follow-up information received on 15/Aug/2006.  The patient's age at the time of the event was 44-years-old, not 45-years-old s previously reported.  Per the reporter, the dose of Decavac was received in the left deltoid, not the right deltoid as previously reported.  The Decavac was administered in the emergency room.  One day post-immunization, not two days post-immunization as previously reported, the patient experienced numbness in the left foot that gradually moved up her leg into the left buttock region.  She also experienced at that time, extreme fatigue, tiredness, pain in the left leg and hip, and generalized muscle aches.  Her left arm had also begun to ache between the elbow and shoulder area.  Two to three weeks post-immunization, the patient reported heart palpitations.  Three to four weeks post-immunization, the patient's numbness worsened and included the entire spine and head.  The numbness was intermittent with sensations of electric shocks occurring off and on daily.  Four weeks post-immunization, the patient developed vertigo, hearing loss, intermittent tinnitus, and blurred vision that made her unable to see directly in front of her, and she needed glasses to see her plate of food.  On 15/Aug/2006 or approximately 8.5 months after the Decavac vaccination, the patient reported having a rash (red spots) that had recently appeared on the inner knee of her left leg.  This progressed to be a generalized red rash over her entire body.  The patient reported that she was unable to do any activities of daily living because of the continued vertigo.  The patient reported that she had been evaluated by an infectious disease specialist, four neurologists, a naturopath doctor, and a multiple sclerosis specialist.  MRI showed 4 white spots that the physician suspected were due to migraine headaches.  CSF culture was negative for any pathogens, and viral testing was negative for Epstein-Barr virus.  Lead and mercury testing showed high levels, but the levels were still below toxic.  Per the patient, the diagnosis of multiple sclerosis, Quillian-Barre syndrome, and lupus have been ruled out.  In Aug 2006, the patient was seeing an Ears, Nose and Throat specialist for inflammation of the the inner ears and eyes, unresponsive to steroid injections.  She was also taking Valcyte for possible viral infection (noted Cytomegalovirus), and had previously been hospitalized for 7 days, but could not remember the dates of admission or discharge.  Treatments received for these adverse events were not reported.  Due to the clinical significance of the reported events, the disabling nature of some of the symptoms and the fact that the patient was hospitalized, this case has been upgraded to serious.  Due to size limitation of the patient history text field, the information submitted in the previous version has been revised in this follow up.