Age: 17.0
Sex: F
Vaccine: HEPA, TTOX, TYP, YF, HEPA, TD, TYP, YF, DPP, HEPA, TYP, YF
Symptoms: Malaise, Muscular weakness, Respiratory failure
Clinical narrative: Information has been received from a health professional through an enhanced surveillance program conducted by the CDC concerning a 17 year old female with Raynaud's phenomenon who on 2/11/04 was vaccinated with a dose of hepatitis A virus vaccine inactivated (lot number and route of administration unknown). Suspect therapy administered that day included a dose of yellow fever virus vaccine (lot number and route of administration unknown) a dose of typhoid vaccine (lot number and route of administration unknown), and a dose of diphtheria toxoid/tetanus toxoid (lot number and route of administration unknown). The patient received these vaccinations in preparation for travel to another country. Concomitant therapy included naproxen, which was taken concomitantly for Raynaud's phenomenon. On 2/18/04, one week after administration, the patient was admitted to the hospital ICU with a one to two day history of weakness in walking, a general ill feeling, and shortness of breath. She was started on BiPAP for decreased respiratory function. She was seen by a neurologist and her diagnosis was thought to be most likely Guillain Barre Syndrome, but it was an unusual presentation for such. Myasthenia gravis antibodies were negative. CBC's were predominately within normal range. WBC was in the 3-4 range with about 30% neutrophils and 40 to 50% lymphocytes. HGB was stable throughout. Iron and iron binding studies were normal. Vitamin B12 was normal. Sed rate was normal. UA was normal. Blood gas was 7.39 pH, pACO2 was 44, pAO2 was 105 prior to starting BiPAP. Electrolyte panels were normal including LFTs. CPK was normal. TSH was normal. Protein electrophoresis was normal. Spinal tap had 1 RBC, 1 enucleated cell, 24 protein, glucose of 58, and negative culture. RPRs were nonreactive. Lead test was normal. EMG was normal. CXR was negative. EKG did show some sinus arrhythmia, but due to the hospital course and clinical suspicion, Guillian-Barre variant was the most likely diagnosis. The patient was transferred from the ICU to the medical floor. Respiratory function improved. She had some peripheral weakness and decreased reflexes so Guillain Barre variant was thought to be the most likely diagnosis. She was weaned off BiPAP. She was discharged on 2/23/04, five days after admission with adequate pulmonary function, although still decreased from presumed baseline. Her activity was as tolerated with outpatient Physical and Occupational therapy follow up, and she had a wheelchair to use as needed. Other laboratory data included a CSF sample that was collected on the day of onset, 2/18/04. The sample was negative for Yellow Fever vaccine virus in TaqMan PCR and also negative for Yellow Fever IgM antibody on ELISA testing. It was suggested to submit a convalescent serum sample to determine whether the patient developed an appropriate response to the vaccine. On 3/6/04, the treating physician agreed to obtain a convalescent serum sample. The physician had not seen the patient in several days and will contact the mother to bring her in to obtain the sample. The patient's medical doctor was spoken to on 3/18/04, about one month after discharge, and he said that the patient had not completely resolved her weakness and still had poor endurance. In follow up information it was reported that the pt had been vaccinated with a dose of hep A vaccine and not hep A virus vaccine inactivated as previously reported. Therefore WAES0406USA01554 is being deleted from out files on hep A virus vaccine inactivated. Other business partner numbers included: 200401834.Follow up 02/0705: From additional information received on 11/15/04 it was reported that the YF-VAX vaccine was administered subcutaneously in the right are, the Typhim VI vaccine, was administered intra muscualry in the left deltoid, the hepatitis A vaccine, manufacturer SmithKline, was administered intramuscularly in the right deltoid and the Td adult vaccine, was administered intramusclarly in the left deltoid. According to the admission note provied, the patient was walking up stairs and doing her work. She had a general feeling of not feeling right the day proceeding admission. She had significant decrease in her lung function and increase in work of breathing and feeling short of breath. The patient had quite an uncomfortabe sensation in her anterior chest and abdoment, that she described as a feeling of needle pricks or tingles that radiated up her back. She seems to have some mild mild stomach cramps and yesterday felt lightheaded but was not syncopal. To date the patient has a mild headache and has felt queasy. The patient does have some Raynaud's phenomenon for which she takes Naprosyn. Her neurologic evaluation included a significant differential for neuromuscular weakness, of which Gullain Barre was felt to be the most likely. The patient was treated with IV IG therapy for the presumed Guillain Barre. Over the hospitalization the patient showed steady improvement every day. She continued to show improved respiratory function and was discharged home on 02/23/04. From additional information received on 11/22/04, through an enhanced surveillance program conducted by the CDC and prevention (VAERS number 21775), it was reported that the patient required outpatient physical therapy for residual weakness at the time of hospital discharge, but was mostly recovered. Per the reporter, the patient fully recovered from the events.