Age: 18.0
Sex: M
Vaccine: FLU(H1N1), FLUN3, HEPAB, MNQ, TDAP
Symptoms: Blood folate normal, Blood immunoglobulin G normal, Blood immunoglobulin M, Blood iron normal, Blood lactate dehydrogenase decreased
Clinical narrative: Pt was in good health at the time of vaccination. 2/24/10 he noted a headache, chest congestion, N, V, rhinorrhea and sore throat. Over the next 42 days the pt was seen for complaints of sore throat, nausea and vomiting, folliculitis, dental pain and scrotal pain-each were treated and symptoms resolved. On 4/19/10 he began to suffer from a headache (pressure behind his eyes, 3/10), after gas chamber training. The headache worsened the next day to a 6/10. On 4/21/10 the headache was described as pressure behind his eyes and temples. Around 1200 the headache became severe (10/10), the pt became dizzy and he fainted. The pt was admitted to hospital with diagnosis of cerebellar ataxia. PE: BP: 140/68 otherwise VS wnl, "high-frequency pendular nystagmus in vertical direction in primary gaze, esotropia, gaze-evoked sustained nystagmus which changes directions depending on gaze; normal tone and strength; symmetrically slowed speed of finger and foot tapping bilaterally which becomes irregular with increasing speed; mild dysmetria on finger-to-nose testing; nl DTRs; unsteady but symmetric gait; neg Romberg". After 2 days the pt was transferred back to BNH (diagnosis cerebritis) for continued observation. At hospital the pt was afebrile and VSS. His nystagmus and ataxia persisted although there was observed improvement of the pt's ataxia when distracted. The pt was evaluated by neuro-ophthalmology on 4/29/10. Impression: "pendular nystagmus with gaze-evoked nystagmus secondary to pontine/cerebellar dysfunction possible Bickerstaff's brainstem encephalitis". The pt was transferred to facility 4/30/10. He complained of headache, photophobia and generalized myalgias. The pt was initially treated with plasmapharesis (beginning 5/1/10) which was discontinued when his symptoms were unchanged after 5 cycles of plasma exchange. 5/4/10 the pt was transfused with 2 units of FFP. 5/12/10 ophthalmology consult: "worsened nystagmus, abduction deficit, conjugated palsy and upgaze deficit consistent with pontine involvement. On 5/18/10 the pt was started on high-dose steroids (1gm IV x 3 days) with no improvement of the patient's symptoms or exam. He was transferred to acute rehab on 5/20/10 with the discharge diagnosis of brainstem syndrome and the following assessment: "exam not consistent and movements greatly exaggerated; although we feel there is perhaps some real baseline abnormalities in terms of his extraocular eye movements, there is no consistent evidence that his ataxia is real." The pt received intensive physical, occupational, visual and psychological therapy while at medical center from 5/20/10 to 6/29/10. Inconsistencies were noted in his ocular symptoms and gait instability. He was referred to Medical Center for neurological exam. It was concluded that the pt's symptoms and exam findings were "likely of psychogenic origin". His ataxia and visual sx improved while in rehab. The pt was also diagnosed with adjustment disorder. The pt transferred back to other facility on 6/29/10. The pt was noted on several occasions to display unusual behavior and then denying recollections of these events. Also he experienced an episode of expressive aphasia on 8/13/10 (pt could say words but could not form sentences) which resolved with after breathing relaxation techniques were implemented. There was concern that these events might be a reflection of a subacute hepatic encephalopathy. On 8/20/10 the pt underwent a transjugular liver biopsy for which was wnl. The hematologist could not explain the pt's abnormal coagulation studies but indicated that there is no underlying liver disease or evidence of Wilson's disease. The pt seems to be making slow clinical improvement related to his ataxia and nystagmus. Additionally, the pt's hypoceruloplasminemia and hypofibrinogenemia are thought to most likely be preexisting conditions. Symptoms: Aphasia (784.3), photophobia (784.94), Muscle Ache(781.01), Dizziness and giddiness(780.4), Syncope and collapse(780.2), Lack of coordination(781.3), Symptoms involving head and neck(784), Headache(784.0), Headache(784.0), Nasal Congestion(784.71), Symptoms involving respiratory system/chest(786), Nausea with vomiting(787.01), Pain, throat(784.1).