Age: 19.0
Sex: F
Vaccine: ANTH
Symptoms: Nausea, Nuclear magnetic resonance imaging brain normal, Red blood cell sedimentation rate normal, Syncope, Tremor
Clinical narrative: VHC re-contacted by pt mid-Jun 2009 & reported recurrent headache, dizziness, nausea, blurred vision, & fatigue which developed about 2 weeks following receipt of AVA#2 given 3/31/2009. Source of information was thru pt phone interview & AHLTA records: she reported feeling well, except for fatigue, from 2/17/2009 to 4/12/2009 (2 months). She was well on date of AVA#2 receipt, About 2 weeks post-vaccination, on 4/13/2009, she had recurrent headache, dizziness & blurred vision. On 5/4/2009 she saw PCM evaluation of these symptoms & reported an episode of difficult arousal from sleep & feeling "confused" at times. PCM considered possible seizure disorder, ordered brain MRI & neuro consult. Non-contrast brain MRI on 5/8/2009 was negative. On or about 5/9/2009 pt reported convulsions involving her right arm, but without LOC, post-ictal state, or loss bowel/bladder function. She was taken to ER & evaluated for this as well as for continued headache dizziness, blurred vision. ER exam, visual acuity, IOPs, labs (chemistry, hCG) & CXR were normal/negative; shortened PR Interval noted on EKG. Simple partial seizure was considered. On 5/13/2009 neurology evaluated pt for dizziness, convulsions, headaches, visual problems, collapsing, & single episode slurred speech after awakening. Neuro exam & MMSE were normal. Neuro considered seizure/sleep/psch disorders, migraine vs. tension headache. She was given trial of nortiptyline for headaches; sleep deprived EEG, labs, psych consult were ordered. Labs indicated normal ESR, CBC, TSH/T4; positive Mono screen; low positive ANA (titer 1:40, speckled); Initial EEG 6/2/2009 reported asymmetric posterior alpha, possibly indicative of differential asymmetric electrode-cortex distance (usually due to relative increased skull thickness); not indicative of increased proclivity for seizure activity; no focal slowing or epileptiform activity; repeat EEG 6/11/2009 indicated normal awake and sleep states; no focal or epileptiform abnormalities. On 6/3/2009 Infectious Disease (ID) evaluated pt for positive Monospot (form 5/13). Her history indicated no prior history febrile illness or URIs in preceding several months; recent normal CBC made recent infection unlikely. EBV Ab panel was consistent with past EBV infection. ID considered: prolonged fatigue possibly secondary to pat EBV infection; Intermittent weakness, headaches, seizures not classic for post-mono complaints; yellow fever vaccination given in Feb 2009 could result in pt's complaints but usually occurred 1-3 weeks after vaccination not months later. On 6/3 & 6/19/2009 mental health & Psych evaluations elucidated no prior psych history, suicidal or homicidal ideation, or current major stressors other than pt's concerns about impact of her illnesses on her military career. Diagnosis was Psychological factors affecting Physical condition (HA, fatigue, etc.). Counseling service was offered but pt declined. On 6/23/2009 per VHC follow-up phone call, pt reported 1) diminished episodes of bilateral arm & left leg "tremors", described as muscle twitching or jerking (once per week) & usually occurring upon awakening, especially if started; 2) slightly increased headache frequency over past week (3x/week) which have responded better Excedrin & sleep rather than to Maxalt;3) less blurry vision, usually occurring in mornings. She is currently on medical profile. 2nd neuro opinion is being considered.