Age: 4.0
Sex: M
Vaccine: MMR, HIBV
Symptoms: Hypokinesia, Mental retardation severity unspecified, Otitis media, Restlessness, Sleep disorder
Clinical narrative: Information has been received from medical records regarding a case in litigation concerning a 16 month old male with no known drug allergies and with asthma (since 11/88) and a history of an upper respiratory infection (11/3/1988), otitis medic 11/3/1988, gastroenteritis 3/13/1989, thrush 3/13/1989, diaper dermatitis 3/13/1989 and viral syndrome Jan 1989. The pt was born at 38 weeks gestation, with no problems during pregnancy or delivery. Following delivery, the pt was noted to have significant amounts of mucus and fluid in his lung (noted to be mild respiratory distress), but was discharged on day 2, He had several episodes of otitis media, first one recalled at 7-8 weeks, and had some early problems with reactive airway disease, requiring occasional Alupent treatments. The parents felt that his neonatal period and infancy were related unremarkable. The pt has one full brother, healthy with no developmental abnormalities, and three half siblings, all healthy and normal. There is no family history of developmental delay or seizures. On 8/8/1989 (in the left leg with a 0.5ml dose) and 8/27/1992, the pt vaccinated with a dose of MMR II. Suspect therapy included on 7/9/2001 (manufacturer unknown) and 2/28/2004 (0.5ml IM in the left arm lot 640033/0413L) a dose of hepatitis B vaccine, recomb and on 11/20/1998 in the left leg a dose of Hib conj vaccine manufacturer unknown. Concomitant vaccinations included a 0.5ml first, second, third, and fourth dose of Poliovirus vaccine live oral on 6/23/1988,  8/30/1988, 11/1/1988 and 8/8/1989 and a first, second third and fourth (administered in right leg lot LED0584K) doses of DPT on 6/23/1988, 8/30/1988, 11/1/1988 and 8/8/1989. At approximately 16-17 months of age, in approx Aug 1998, the parents noticed that the pt did not respond to sounds, or notice people come into a room until he could see or be touched by another. First audiometric testing was performed in Jan 1990, revealing inconsistent responses to sounds at all levels. PE tubes were placed in May 1990, and although no fluid was reported seen, the pt did seem to improve subsequently, and began to respond to some sounds, and repeat audiometry confirmed relatively normal hearing. Of note he did say dada and oh oh at age 9-10 months, but as of 10/5/1990, when he was admitted to the hospital for d days for evaluation of developmental delay, he no longer said these words. He babbles, cries, screams, whines but utters no recognizable syllables. He communicates and makes his needs known by pointing or showing. He did not listen to verbal commands. He tends to become easily frustrated, impatient, and has little impulse control. He has not been toilet trained. He has been noticed to have several episodes of blank staring, lasting less than a minute, with quick resolution, He is also noted to have very erratic sleep patterns. The impression was developmental delay, most marked in language, but also with prominent motor and behavioral delay. On 12/12/1999, the following lab results were obtained MRI of the head slight increased signal in periventrical region c/w delayed myelination, EEG normal, BAERS normal, CBC normal, P4 normal except for SGOT 66, LDH 316, ALK 302, serum lead levels normal, sickle cell trait positive. Impression chronic encephalopathy manifested by sever language delay and evidence of cognitive delay. The pt was later diagnosed with autism/mental retardation. Information received contained the following adverse events upper respiratory infection 4/15/1991, otitis media 11/11/1991, pneumonia 4/10/1990, ingested candle lighter fluid 8/13/1993, chickenpox approx 2/1990, PE Tubes placed May 1990. Upon internal review, mental retardation was considered to be an other important medical event (OMIC). Additional information has been requested. All medical records available upon request.