Age: 2.0
Sex: M
Vaccine: DTAP, HEP, HIBV, OPV, DTAP, HEP, HIBV, IPV
Symptoms: Sleep disorder, Speech disorder, Urinary incontinence
Clinical narrative: Developmental history revealed that the vaccinee appeared to be "developing normally and talking in single words in a meaningful way until about 2 years of age."  The physician who made the dx of pervasive developmental disorder stated, "His immunizations are up-to-date and he has had no bad reactions to them." Speech delay was 1st documented in medical records of the PCP on 12/14/99, when the child's mother left a telephone message concerning her son's speech delay problem and the need for a referral. On 1/3/00, a phone message was left for the PCP concerning the pt's speech delay and hearing problems and the need for referral. The child underwent an audiological evaluation on 2/8/00. The right revealed a flat tympanogram, consistent with effusion, but since his positioning was poor and he was moving and crying there is a large margin for error". The child underwent a communication evaluation on 2/9/00. The pt reportedly uses mostly single words, does not speak in sentences, will no respond or answer back to questions, sometimes is hard to understand and that he seems to miss the first word of sentences when he tries to talk. The mother stated that the child stopped talking at age 2, then when the family relocated he "stopped progressing, that once a skill was "mastered" he would not repeat it." His play behaviors were repetitive actions. He attempted to push small toys up his nose. He tends to lick things frequently. He tends to laugh for no reason. Toilet training had been coming along well, but then stopped. His sleep is characterized by frequent waking at nighttime. He had atypical social interactions. Subsequently, the parents of the pt alleged that the pt developed the "neurologic effects of mercury poisoning" as a result of being vaccinated with thimerosal-containing vaccines. As of 7/5/01, the outcome of the pervasive developmental disorder was unknown.F/U the most recent info was rec'd on 9/14/01. As of 5/14/01, the pervasive developmental disorder and autism were ongoing. The outcome of the mercure poisonign was unknown pervasive developmental disorder, autism and mercury poisoning are considered medically serious. 5/16/01 occupational therapy evaluation: the peabody developmental motor scales II instrument provided the following results:basal age (lower skill level) grasping 11-16months, visual 19/22 months. ceiling age (highest skill level) grasping 41-48 months, visual motor 25-28 months. Ths sensory profile instrument provided the following relsuts: probabble difference in touch processing, modulation related to body position and movement, modulation of movement, affectin level, modulation of sensory input affecting emotional responses, modulation of visual imput affecting emptional responses and activity level, definite difference in auditory processing, vestibular processing, oral processing, emotonal/social responses behavioral outcomes of sensory processing. The Easter seals ADL chesklist instrument revealed delays in dressing, grooming and toileting. F/U states, On 5/17/00, the child was seen by a physician specializing in "integrative treatments". The physician noted "hyperactivity", perenial allergies and speech delay. He has several deficiencies; he has parasites; heavy metal toxicity and nutritional deficiencies. The mother was instructed to decrease milk and egg whites in the child's diet. Unspecified supplements were dispensed. On 6/15/0, a 10-day course of nystatin was prescribed for an unspecified indication. Seen by this doctor on 7/19/00 and he noted "He started taking his supplements and has some difficulty eating a lot of food. His bowel movements have slowed down to a couple a day. He went over again the toxicity problem. We should go ahead and proceed with the urine challenge prior to starting chelation and urine DMSA. On 8/16/00, UTE screen "post provocative challenge" showed an elevated tin concentration. Mercury concentration was below the detection limit. A letter written by the child's father on 8/16/00 stated, "Simply put, (he) suffers from mercury poisoning whose characteristics are strikingly similar to autism related disorders". This letter was signed by the physician. On 11/13/00, UTE screen showed elevated concentrations of lead, mercury and tin. After seeing child on 11/30/00, the doctor stated we need to continue chelation and also we should consider exploring the amino acid, fatty acid dysfunction. On 2/15/01, the child was seen and is doing well with the chelation; has minimal nasal discharge. Cut back to 70 g X 2 a day for 3 weeks. On 4/10/01, he has increased hyperactivity and the previous abnormal behaviors to a greater extent. F/U states: The child began speech and language therapy on 4/4/00. He began twice weekly occupational therapy sessions on 6/19/01. In the pathologist's session note of 7/31/01, she wrote, "Dad reported (the child) is starting to have "his own thoughts", "answering questions". The child's mother reported that three cousins had unspecified "speech problems," one cousin had attention deficit disorder, and one aunt had an unspecified mental illness. Also adds that on 06/15/2000, the integrative treatments physician prescribed a 30-day course of nystatin to treat "an intestinal yeast overgrowth." On 08/18/2000, the child underwent a special education evaluation by his local public school district. At that time, his mother reported that "he has a previous diagnsis of pervasive developmental disorder, but this has since been changed to mercury poisoning and severe food allergies which cause similar characteristics." His mother wrote," since begining an organic diet with numerous supplements two months agi, we have seen a dramatic change in eye contact and interaction with others and an increase in vocabulary - using verbs, pronouns and putting words together." The mother indicated that the child communicated most of the time with gestures, single words, and two words together. She reported that his family members understood 75 % of what he said and strangers understood 50% of what he said. The child was "trained for urinating, but has trouble controlling bowels - refuses to go on potty. Supplements cause him to have very loose stools." The child drank from a cup, which or without a lid; fed himself with his fingers, a fok, and a spoon; undressed without assistance, took off his shoes and washed and dried his hands. The child was evaluated using a transdisciplinary play-based assessment, the childhood autism rating scale and the Gillian autism rating scale. His score on the childhood autism rating scale was 30, which on the rating scale was the borderline between "non-autistic" and "mildly-moderately autistic." His autism quotient on the Gillian autism rating scale was 82, which placed him in the "below average probability of autism" group. The evaluators found that the child was "age-appropriate in the ares of self-help and gross motor skills. He demonstrates qualitative impairment in social interactions and communication. In addition, some disruptions in sensory responses and play and interaction with materials and toys were observed. These behaviors may be consistent with an autism spectrum disorder. He shows an educational need for special education services because preschoolers received and express a large amount of information about themselves and their environment through communicaiton, social interactions, and learning from a variety of materials, and are therefore at a disadvantage when these abilities are delayed. It is recommended that he attend the preschool to be provided two hours per week within the classroom time." The evaluators certified that the child qualified for special education services on the basis of three "identified disabilities"non-categorical early childhood speech impairment, othe rhealth impairment." On 09/06/2000, the physician completed a physical disability, eligibility report, indicating that the child had "limited strength, vitality, or alertness due to chronic or acute health problems which adversely effect his educational performance." The health problems was noted as "heavy metal toxicity" which caused moderate impairment. The function implications of the impairment were reported as "difficulty with self-help skills, difficulty performing activities found in a general classroom, adaptation to the general program, difficulty to maintaining alertness in the general classroom, and difficulty with the short-term memory." The child participated in the preschool program for children with disabilities from 09/13/2000 to 09/11/2001. As of the September 2001 assessment, he had mastered 12 of the 22 short-term objectives defined at the beginning of the program and was close to mastering an addtional seven short-term objectives. The school district recommended that the child remain in the preschool program for the September 2001 to September 2002 school year, but extended to the full-day program. The most recent information was received on 01/30/2002. As of 09/13/2001, the pervasive developmental disorder and autism were ongoing. The outcome of the mercury poisoning was unknown. The follow-up states that MRI of the brain was performed on 06/08/2001; the radiologist's impression was "normal brain pattern." Overnight electroencephalography was performed from 07/23/2001 to 07/26/2001. The neurologist's impressions were "abnormal videoelectroencephalography monitoring demonstrating spikes and sharp waves fromt the right frontocentral region. This EEG emonstrates emilantiform activity. No clinical seizures were noted. A pattern of Landau-Klaffner was not seen." DNA probe analysis for Fragile X syndrome was negative on 08/07/2001. Amino acid concentration measured to 08/07/2001, were within the reference ranges, with the exception of a reduced concentration of valine. On 08/10/01, the child returned to the pediatric neurologist. The neurologist wrote that the child "is a 4 year, 11 month old boy wiht autism. He underwent a neurologic work-up in June and July. An MRI brain is normal. Overnight epilepsy monitoring for sleep EEG is abnormal with occasional generalized spike and wave. The pattern is not consistent with Landau-Kleffner syndrome. Serum chemistries are normal except for a platelet count of 15,000. Large groups of clumped platelets suggest that the platelet count is falsely low. His examination remains unchanged. Recommendations: 1. discussed the nature of the abnormal EEg with his parents. Although the EEg pattern is not suggestive of LKS, I have offered the parents an empiric trail with either an anticonvulsant medication or oral prednisone. Potential side effects of each therapy were discussed. The pt's father is not interested in such therapy with, admittedly, unlikely benefit." The most recent info was received on 06/25/02. As of 09/13/01, the pervasive developmental disorder and autism were ongoing. The outcome of the mercury poisoning was unknown. The follow up states family history was significant and one aunt had depression. On 5/24/02 and 6/14/02, the subject was evaluated by a pediatrician for "a second opinion for treatment." The pediatrician took an in depth new pt history from the subject's father. The subject's current medications included an unspecified nabulizer for breathing as needed and multivitamins and mineral supplements. He was receiving occupational and speech therapy. When the subject's father was questioned regarding immunizations and reactions, he indicated there were "one or two times that he might have had a problem." The subject was still for the most part on a gluten-and-caseine-free diet with "some" wheat and dairy. At the time of the evaluation, he was able to use a spoon, fork, and cup without a lid. He was not toilet trained. The father reported that the subject "has leaky gut" with yellow stools. It was noted that the subject "now has hundreds of words." However, he could not tell a story or carry on a conversation. The subject liked to be red to, recognized other words, looked at books "independently," recognized the alphabet and recognized his name. The subject could draw shapes and print his name with assistance. He knew numbers from one to 36. His father indicated that he "obsessed" on videos and books. His father ntoed he could build with Lego's and his stacks had to be even and very meticulous. His gross motor skills were "phenomenal" and his fine motor skills were weak. He overreacted to loud sounds. His father stated his son "began to withdraw then had more issues with screaming. Now he has on and off days-on worst days-he swats at people if cant' do what he wants." It was noted that transitions could be hard for him. His social skills were limited. He played with his brothers, but had on interest outside of his family. His father stated, "He does his own thing. He is fearless." The subject had received three courses of chelation therapy with DMSA and was noted to have had behavior problems secondary to it on 11/30/00. The pediatrician made a diagnosis of "speech disorder" and recommended speech therapy twice weekly for one year for a speech disorder and a comprehensive stool analysis. She wrote that she would prescribe 'meds if behavior worsens." She also referred the subject to anotehr physician. The most recent info was received on 9/16/02. As of 4/11/02, the pervasive developmental disorder and autism were ongoing. The outcome of the mercury poisoning was unknown. *Follow-up report on 10/10/2002: On 11/6/01, the child began occupational therapy twice weekly for myofescial release and craniosacral therapy. On 4/11/02, after approximately 5 mts of therapy, the physical therapist wrote, "Currently he has trouble dressing himself and continues to require help. He is potty trained for urine (although has a tendency to urinate in unwanted places). He is still not trained for bowel movements. He is able to feed himself but is unable to cut his food or organize himself for school. He has a 2 y.o. brother and will play alongside him, although tends to be overly aggressive at times. At school he requires an adult to always be present.... ASSESSMENT AND RECOMMENDATIONS: [The child] is an active, busy little boy who appears to be significantly struggling in his 2ndary motor development and modulation of sensory input. This will contribute to difficulties interpreting sensory stimuli, motor planning and skill development. These all lead to behavioral issues. He is currently showing significant deficits w/in his foundation and coordination areas. These include low endurance and tone, poor tactile discrimination, modulation issues and fine motor/ perceptual difficulties. These issues are all related to his vestibular and propriceptive systems. His motor development roughly demonstrates scattered abilities more typical of a 2 to 3 y.o, as compared to his 5 and a half year chronological age. While he initially appeard to be quite capable motorically, his impulsivity and lack of safety awareness presents a significant risk to him. Sensory Integration therapy has been found to be beneficial in promoting adequate foundstion skills and abilities, paving the way for higher function. This is not a quick fix therapy and will likely take several yrs to create the pathways necessary for more organized function. I would recomment a minimum of 2 physical/occupational therapy sessions per wk. At the end of a 6-8 mt period we will re-assess him to determine how quickly things are coming together for him.. We  have found that progress is maximized when a combination of craniosacral and sensory integration techniques are used." The most recent info. was received on 7/16/02. As of 4/21/02, the pervasive development disorder and autiasm were ongoing. The outcome of mercury poisoning was unknown.