Age: 73.0
Sex: M
Vaccine: LYME
Symptoms: Musculoskeletal stiffness, Myalgia, Mycoplasma serology positive, Nuclear magnetic resonance imaging brain normal, Paraesthesia
Clinical narrative: This case was reported by a lawyer and described the occurrence of rheumatological symptoms in a male subject of unspecified age who was vaccinated with LYMERIX (GlaxoSmithKline). A physician or other health care professional has not verified this report. On an unspecified date the subject received unspecified dose of LYMERIX (unknown). According to the statement of injuries, at an unspecified time after vaccination with LYMERIX the subject experienced "joint pain, flu-like symptoms, fatigue, rashes, tingling in extremities, headaches, memory loss, cognitive dysfunction, muscle pain, numbness, imbalance, weight loss, and decreased activities of daily life". The statement of injuries also alleged that the subject experienced "rheumatologic, neurologic, and/or cognitive impairment of an autoimmune, immune-mediated, or other mechanism all caused by vaccination with LYMERIX including but not limited to those set forth above." At the time of reporting the outcome of the events was unspecified. Follow up information was received on 08 September 2008 via medical records. On an unspecified date during or prior to 2004, the subject was diagnosed with dementia. On 09 January 2004 and 09 February 2004, the subject reported increasing joint problems/joint pain. On 30 March 2005, he reported decreased memory. In August 2006, the subject underwent ambulatory electroencephalogram monitoring due to hypersomnolence, memory loss, agitation, joint pain and Lyme disease. The subject was diagnosed with dementia on an unspecified date. On 10 January 2007, the subject's wife contacted his health care provider to inform that the subject was hospitalized and "they stated he doesn't have Lyme". In January 2007, the subject was experiencing end-stage dementia and was going into a nursing home. On 22 January 2007, the subject's internist was consulted and it was noted that the physician had been managing the subject's "chronic Lyme disease" and was reportedly "unaware of the wife's concern that this is demyelinating polyneuropathy secondary to the Lyme vaccine". The internist noted that the subject had been ambulating a few months prior to the date of evaluation "and that this rapid deterioration could not be secondary to dementia alone". A trial of ROCEPHIN was recommended. He was admitted to a nursing home for end stage dementia. On 01 February 2007 he was noted during a neurology examination of have a history of Lyme disease "with tick bite and bull's eye rash in the late 1990's. He was reportedly "given vaccine" two years later and developed symptoms including dizziness, ataxia, back pain, poor vision, stiff neck, and weight loss. He was noted to have "dementia with Lewy Bodies", with gradual memory and cognitive decline. The subject was hospitalized on 04 February 2007 due to progressive lethargy, dehydration, and sepsis. He was obtunded upon admission and remained so throughout admission. He was admitted to the intensive care unit due to hypoxemia, aspiration risk, and "feeling that he was heading toward worsening and respiratory failure:" Initially he was "a full code as it was his wife's feeling that this was all secondary to Lyme disease and not Lewy body dementia". Treatment included intravenous fluids and antibiotics without change, and he was moved to a medical floor and the family made the decision to "do not resuscitate" (DNR). He progressed in a downward fashion until he expired under comfort care measures on 15 February 2007. The specific cause of death was not provided. Diagnoses were 1) end state Lewy body dementia, 2) chronic failure to thrive, 3) history of Lyme disease, 4) aspiration pneumonia, 5) dehydration, 6) protein malnutrition. 9/24/08-death certificate received-COD-Sepsis. Lewy Body Dementia