Age: 60.0
Sex: M
Vaccine: HEPA, TD, YF, HEPA, TD, YF, DPP, HEPA, YF
Symptoms: Demyelination, Hemiparesis, Paresis, Skin ulcer
Clinical narrative: It was reported that a 60 year old male pt received Yellow Fever vaccine, lot number and manufacturer not reported, TD, lot number and manufacturer not reported, and Hep A vaccine, lot number and manufacturer not reported, all administered on 4/4/02. Approximately six days later the pt developed left leg weakness. His left-sided weakness subsequently progressed, and by early May he was paretic on the left side. Subsequent workup indicated a demyelinating syndrome, and he was treated with high-dose steroids. The pt has subsequently improved to the point that he is ambulating independently without use of a brace or a cane; rehabilitation has been remarkably successful. According to the CDC report, the major diagnostic issue at hand is whether this pt's demyelinating condition was more consistent with acute disseminated encephalomyelitis, a monophasic demyelinating condition sometimes seen in the setting of vaccination or viral infection; or if in fact his condition represented a forme fruste of multiple sclerosis. The pt indicated that he had been previously healthy prior to the onset of his neurologic illness in April 2002. He had never experienced any transient neurologic events such as weakness, numbness, paresthesias, neurologic events; no one in his immediate family had received a diagnosis of MS. The approximate interval from his vaccination to onset of symptoms was around 7 days. His illness progressed rather slowly, progressing to point of maximal weakness over the period of about 30 days. To date, he has slowly continued to improve, and he has experienced no subsequent relapses or periods of worsening. He has had no further neuroimaging studies or CSF analyses performed since October of 2002, at which time his MRI displayed some amount of resolution of the larger areas of demyelination, as well as several small static white matter lesions. Data on CSF, which was apparently collected at least twice, has been unavailable for review, but is in the process of being obtained. For the most part, however, CSF indices are poor differntiators between ADEM and MS. According to the CDC report, given the nature of this pt's illness, the lack of relapse or progression, a slow temporal relationship to several vaccinations, the presumptive diagnosis of ADEM is quite likely. Such a slow progression, over a period of 30 days, is a bit long for this clinical entity, but is certainly not exclusionary. A diagnosis of ADEM does not allow for determination of which vaccination might have instigated the demyelination (or, for that matter, whether one of the vaccinations was indeed the instigating event). However, association with vaccination is based on temporal relationship, and the 7-8 day interval between vaccination and onset of symptoms would be consistent. This would appear to be a case of ADEM, most likely related to receipt of  one of three vaccinations. From additional info received on 10/7/03 from telephone contact with the Center for Disease Control, the pt's name and birthdate were provided. The pt's age at the time of the onset of events was changed to 60 years. No additional info was provided. From additional information received on 12/21/03 from the Centers for Disease Control and Prevention, it was reported that the patient was 61 years old at the time of this event, however, as per the patient's date of birth and date of adverse event onset, the patient's age calculates as 60 years. The patient received the vaccinations in preparations for a trip overseas, but returned to the USA after the onset of events and was hospitalized shortly thereafter on 5/6/02. A neurological exam was notable for 3+/4- strength throughout on the left side. Initial radiological studies concerning for R-sided neoplasm, infection or demyelination. The patient was started on Decadron and underwent stereotactic biopsy, which showed a demyelination process. The patient was transferred to rehab medicine on 5/31/02 and discharged on 6/21/02, with intensive physical and occupational therapy and neurological follow ups. On 12/02, the patient was judged to be able to drive. The final decision for this case was suspected yellow fever vaccine-associated neurotropic disease. Acute disseminated encephalomyelitis was determined to be an other important medical event. No further information is available. From additional information received on 12/21/03, it was reported that the patient underwent stereotactic biopsy, which showed a demyelinating process.