Age: 58.0
Sex: M
Vaccine: PPV
Symptoms: Abasia, Balance disorder, Difficulty in walking, Guillain-Barre syndrome, Hypoaesthesia
Clinical narrative: GBS. Pt received his pneumonia vaccine on 9/16/03. Around 9/25/03, he began experiencing trouble with his balance and his ability to walk. He began experiencing weakness from his feet to his knees. The weakness later progressed to his thighs and his groin to the point of being unable to walk by 9/29/03. On 9/30/03, he received a walker and did okay until 10/2/03, when the numbness progressed up his legs, into his back, as well as into his hands and arms. On 10/2/03, he felt as if he had no control of his legs or hands. He complained of weakness in the upper extremities along with a tingling sensation on both lower extremities and in the hands and forearms. When he tried to use his hands for fine control of things, they began to shake and "jump around." He had no trouble with swallowing, SOB, visual changes, or headaches. He denied bowel or bladder incontinence. Prior to admission in October, pt denied any history of recent cold or viral infections. On the evening of 10/2/03, pt was admitted to delineate the underlying etiology of his symptoms. On 10/6/03, he developed partial facial sensory loss. On 10/8/03, pt requested a transfer where he was diagnosed with Guillain Barre syndrome. According to pt, he received treatment with IVIG on 10/10 and 10/12. He was also treated with plasmapheresis, five exchanges every other day x 10 days. His symptoms improved somewhat before he was transferred to hospital for further rehab. He remained at rehabilitation until 11/14/03. He was admitted to another hospital on 11/21/03 when he complained of a sensation of "constriction" in his throat. He was observed and evaluated overnight, and then released. Currently, pt continues to experience numbness in his hands, which he describes as feeling like he is wearing "concrete gloves." He is limited to a wheelchair, requiring minimal assistance for transfers. He continues to have outpatient physical and occupational therapy visits. He will follow-up with his neurologist later this week. Pt had been evaluated in the neurology clinic in 5/03 for a long-standing history of diabetic polyneuropathy dating back to 1985. He was referred for evaluation of tingling sensations in his hands that were somewhat painful. He was started on Pamelor for the pain. His lab results at that time were remarkable for an IGM Lambda spike on his SPEP. 60-day follow up on 04/14/04: "Pt has not recovered from adverse events.  Pt reports continued lower extremity weakness and numbness in his hands.  Since initial VAERS report filed, he fell and hurt his right knee and continues to experience knee pain.  He is not able to ambulate secondary to his lower extremity weakness and knee pain.  He uses a wheelchair at home and has obtained a "scooter to assist in getting around".  He is able to carry out most activities of daily living independently despite the numbness in his hands.  He plans to return to work later this month.  He is able to "hunt and peck" at the keyboard.  He is still living with his daughter (he lived independently prior to onset of GBS).  He is able to transfer from his wheelchair to the bed and shower chair using handrails, and his son-in-law has obtained some type of assistance device to get up the stairs.  I have not obtained additional medical records since November 2003, but pt reports continued follow up with his neurologist.  He will soon complete his 3rd course of IVIG with minimal improvement since Feb 2004.  Please contact me if additional information is required." Follow up 12/01/2004: Patient reports weakness and intermittent numbness in his hands. Since his VAERS update report was filed, he has noted some improvement in strength in hislower extremities and the numbness in his hands seems to be decreasing. He says he has no strength in his hands. He is not walking, but he is able to stand and "move each leg a little". In April 2004, he was able to return to work with the aid of a motorized "scooter". He had been receving physical therapy through March 2004. He is trying to resume some type of therapy, but scheduling and the cost have been barriers. He has been receiving monthly treatments with IVIG. After his treatment this weekend, his treatment frequency will decrease to every 3 months.