Age: 36.0
Sex: M
Vaccine: TDAP
Symptoms: Nerve conduction studies, Nerve injury, Nuclear magnetic resonance imaging brain abnormal, Ocular hyperaemia, Oedema peripheral
Clinical narrative: Aug. 1, 2011 Insect bite got infected went to clinic. Dr. gave Tdap and 2 antibiotics; Meclizine 12.5, cephalexin for infection and Staph, 2 hours after felt shortness of breath, dizzy, lightheaded, left shoulder arm tingly called clinic said don't worry keep taking antibiotics. I have been to neurologist - 2 MRI found 1" lesion left temporal lobe, along neurosurgeon, cardiologist, rheumatologist, ENT, ophthalmologist, dermatologist, GI, dentist. No answers! Friday, July29 On Friday afternoon around 4:30p.m. I got in the shower and noticed a bite from an insect of some sort. On Saturday, July went to ask pharmacist to look at it. She said it looked infected and that I needed to go to the doctor. On Monday, August 1 I went to work and reported it to, Safety Director. She advised me to go to the clinic. I saw Dr. Dr. saw my foot and said that I had cellulitis and possible staph infection. She prescribed two antibiotics. One to treat staph and to fight infection. Meclizine 12.5 mg take one tablet by mouth twice daily as needed. The other antibiotic was cephalexin take one capsule by the mouth 4xs a day. That afternoon when I sat down to eat lunch I took the two pills prescribed. Shortly after, I was feeling lightheaded, dizzy, clammy, short of breath and chills. I went home still feeling bad, called clinic, told them my symptom sent back to my they told me everything was fine just continue taking antibiotics. Monday, August 8 Dr. saw for follow up and said that I could go back to work. Tuesday August 9&10 I went back to my regular work load which is installing a/c units. Wednesday, August 10 After lunch and got back to work site I felt lightheaded and dizzy. It was scary feeling was picked up by my boss and driven home. I was told to see my primary doctor which did. I saw Dr. at office. She said didn't know what was going on with me and said to go to the emergency room if I got worse. Thursday, August 11 That evening I felt same symptoms felt lightheaded, dizzy, chills, and clammy. So I went to the emergency room thinking I was having a reaction to the vaccine; tetanus and/or antibiotics. Dr. was 18 attending physician. After having blood test, EKG and fluids given to me, Dr. concluded that there was nothing life threatening was told to go back to work on August 18. Wednesday August 17th Dr. office advised me to return back to work with lightheadedness. Friday, August 19 I returned back to work on light duty in the office. I still feel lightheaded and dizzy. I felt like needles were sticking in my head. My vision seemed to be blurred and severe headache. It's the closest I've felt to deal. I felt that over the weekend. Monday, August 22 I worked all day 8:00-5:00 in the office but continued to feel lightheaded. Tuesday, August 23 I had two Dr. appointments one to cardiologist for echocardiogram and the other to an allergist. I gave blood and administered allergy tests along with asthma. Results were no known allergies at this time. He said it might be possible serum sickness. Safety Director finally gave me a nurse card. She said if anything else comes up medically to contact nurse. Wednesday, August 24 worked for five hours between going to draw blood again for allergy testing and going to have sonogram done on heart. Thursday, August 25 I was still working on light duty in the office I continue to have lightheadedness but I worked 8:00-5:00. Friday, August 26 I worked 8:00-5:00 felt lightheaded throughout the day. Saturday, August 27 noticed red blister on right cheek under eye. It was sensitive and blisters began to get bigger. Sunday, August 28 The blisters went from dime size to a fifty cent piece. I went to Urgent Care I saw Dr. She diagnosed it as Shingles. She prescribed Valacyclovir 1mg Three times a day. I felt achy, lightheaded, clammy, burning sensation, itching. She also prescribed Hydrocortisone cream for itching. Monday, August 29 I went to work 8:00-5:00 still feeling lightheaded and dizzy. I was working in office on light duty. Tuesday, August 30 I went to work 8:00-5:00 still feeling lightheaded and dizzy noticing blister drying up. Wednesday, August 31 I went to work 8:00-5:00 still feeling lightheaded, dizzy and achy. Thursday, September 1 I made appointment to go back to see Dr. at office. She is requesting more blood work. She is continuing to research allergic reactions from vaccine. I am still feeling lightheaded at times. It is sporadic. She has advised me to stay on light duty until all of the tests results are back. Friday, September 2 Blisters are going away but still feel lightheaded at times. Saturday, September 3 late that evening I noticed a knot on the right forearm sensitive, tender and swollen. I don't know what it is. I am finished taking valacyclovir. I still feel lightheaded and dizzy, congested. Sunday, September 4 I woke up dizzy and lightheaded. Monday, September 5 I went to work. I left from desk around 12:00 to go eat as I walked into Cafe sat down felt on edge my left side of face felt numb and tingled. I have pressure in ears and head gets pain in it. Feels like I'm stomping and eyes are blurred vision I feel tired. Coordination is off and this has gone on since August 1 when I was diagnosed with cellulitis in right foot and was given a tetanus shot and prescribed two antibiotics. I'm not the same since this happened. Nothing is changing. It comes and goes. I'm always on the edge. I lose focus can't concentrate and feels like memory plays tricks on me. Sometimes I walk around wondering what I'm doing I forget what I'm doing. My head feels heavy, I'm weak like I was struck by lightning, blurred vision, don't go away. Left side of head around my temple and all on my head. My jaw sometimes feels like Lockjaw and it sometimes slurred speech. Pretty much my left side of face and head my left arm and my knees, my toes and fingers get tingly and numb. My coordination is off and so is my motor skills. I can't think straight I'm sick of it. Even felt nauseous. I have had stomach pains. I feel spaced out---- nose sometimes gets numb and tingly my left eye has been red and I feel brain dead. Tuesday September 6 Just feel in a daze. Wednesday, September 7-October 10 night trying to go to sleep. It was difficult due to shortness of breath. But finally around 1:30a.m. fell asleep with gf. November 3 I got up to go to work. I felt a little off balance eyes blurred and tired. Blisters on face getting bigger. At work answering phones and feeling a little dizzy 11:45 am I went to lunch at 12:30 and I was starting to feel strange again I stopped and ate. I felt I was wired on drugs then when left it was like my throat was tight and was real dizzy and eyes were blurred and felt like I was going to stop breathing and die. My ears, eyes and motor ability was impaired. I am so tired of feeling like this. It's scary. I have dealt with burning sensation in my nose, throat and had acid reflux and nausea, vomiting. I've dealt a lot of pain suffering 2:10 pain in my knees. Last night was feeling weak in legs, arms my head my eyes are weird in legs, arms my head. My eyes are weird. I went to my friend's house and felt like I was going to fall over trying to walk in his door. I was slowed down. Friday, November 4 I woke up tired I'm at work answering phones no attack yet. That evening my energy was very bad. I was dizzy felt retarded like I had blurred vision and was very slow at moving weak knees and arm and legs I went to Dr. Saturday, November 5 Just laid around and was tired weak had blood in my stool twice. Monday, November 7 I went back to my neurologists EEG results were negative. He said didn't find anything that looked to be a worry. As a matter of fact, he said it's probably the Sjogren's Syndrome causing the effects. Tuesday, November 8 8:10 am I went to eye doctor and had an eye exam done and of course nothing wrong that he could see my right eye 20-20 left eye was harder to read the line like the right and was like 20-35. My eyes get red mainly my left eye gets a bull red color day to day. Stayed home blurred vision due to dilation of eyes. November 9 Worked in office answering phones no weird feelings present while sitting it seems to come around eating and sun and heat. I got home around 5:30 pm and started feeling strange. Dizzy, short breath, itchy feet on the top of hands and feet. My joints hurt in my wrists and fingers my hands get splotchy red stripes across them and itch. November 10 Thursday morning woke up feeling dizzy, drunk feeling I have no idea what's going on with my eyes and brain. I feel stupid retarded feeling. I ate some yogurt and couple pieces of chocolate and I'm feeling weird dizzy, short of breath, and my eyes feel weird and my brain something is attacking 9:30 am I feel strange, dizzy and brain. November 11th I went to work feel weird like something going on with my brain and vision. Balance and joint pain, red on hands pain comes and goes feel brain fog. Fatigue dizzy went to rheumatologist; blood test unequivocal for Sjogren's syndrome was referred to dermatology, Dr. look at spot on face needs to be blistered before biopsy. Back at work no changes dizzy. Phone call from a radiologist for an appointment Jan 3. 9:15 am. Saturday, November 12 no change felt a little dizzy. Sunday, November 13 I went to mall walked around for an hour came back to truck and I was feeling tired, dizzy went home and watched tv and around 11:30 I went to lay down as I shut my eyes. I felt short of breath and had a panic of some sort. I had difficult time breathing. I was up to 3:30 am unable to go to sleep my body got numb and tingly. Monday, November 14 I went to draw blood went to lawyers office for consultation stayed with my parents around 10:30 I felt a little numb in my arms. I went to bed on October 10 I went to work light duty in office. I felt weird at 12:30 when I left to lunch feet and toes numb and face numb and tingly, dizzy and lightheaded, driving to go eat. Joints, muscles are weak like I have nerve damage, my eyes are blurred and my head and face are tingly. I cried a few min. and I'm not the same I feel fatigue tired like I don't care anymore. Around 2:45 p.m. I called clinic and talked to someone and told her what all I've been through and she gave me a lot number and the name of the tetanus shot they gave me. Diphtheria Tetanus Exp. 2013 Lot#U3696BA the manufacturers name is SANOFI Pasteur Ingredients she said were Thimerosal, Aluminum Adjutant Residual Formaldehyde. Then she said someone would be getting back to me very soon. Never heard from anyone. I called office to see if they had made my other three appointments. She said she was faxing my referrals to them and I would be hearing from them soon. October 13 Went to another neurologist Dr. to get some answers. They did a serious blood test. Waiting for results. Went home feeling weak and dizzy. My arms felt heavy like lead like I could barely hold anything and it comes and goes. It's a crawling feeling, numbness and fatigue. October 14- went to work answered phones. I did ok up till lunch. I went out to eat and felt weird again like my vision was blurred again, and I was off balance. Friday evening my gf came over. We went to dinner I drove and started having blurred vision in the dark on highway I was feeling weird around 8:00p.m. Saturday, October 15 I went to my parents ranch to get away the day to spend the night. It was a struggle to walk around to the feeders but I tried to work my muscles my vision and balance was off a bit it comes and goes. Sometimes I feel almost normal then here comes that feeling numbness, cramps in arms, joints, blurred fuzzy vision. Itchy on head sometimes feel like needles are stabbing me in stomach and head. Sunday October 16 I felt good most of the day up till the evening around 7:00 pm when I was going to eat I started feeling strange up to be time around 11:00 went to be woke up dizzy, and my fingers and toes and feet were numb and tingle last night, and was having needles stabbing me in my stomach and a pain in my head on left side like crawling weird pains. October 17th Monday morning woke up dizzy drove to work sitting to answer phones my head feels weird and face is a little numb on left side. Someone from my work come in to talk to me to say she and co-worker want to have a conference call meeting with me to go over my vacation time left and my opinions. October 18th 8:30 am went to my neurologist. Dr. to do a nerve study and get blood results and get diagnosed with Sjogren's syndrome. I am being sent to a rheumatologist so I wait. 9:26 am I have a funny burning sensation in my throat esophagus. November 1 - Woke up in the middle of night stomach cramps then had bowel movement went back to bed. Got up again and had acid reflux threw up twice in toilet. I drove to work answering phones. Left work 1 hour early flu like symptoms diarrhea and throwing up. November 2 Stayed home sick getting a little better. That evening noticed red spot on my face started blistering again what was said to be shingles. My head was not feeling right and my vision is still fuzzy. My neighbor said my left eye was red and puffy. That problem. My walking was a little unsteady my knees felt like they were going to buckle very weak. November 15 woke up at 5:50 am a little dizzy. Pain in left eye sometimes itchy and weak. November 16 Pretty much the same comes and goes numbness and dizzy talked to co-worker. He is putting me on short term disability. November 17 Last day of work. November 18-23 weak, slow, fatigue and lots of joint pain I had GI doctor had colonoscopy and upper GI found ulcer in esophagus. (Esophagitis) prescribed NEXIUM. Still feel lightheaded, fatigue and dizzy, and joint pain. November 29 went to Dr.; she referred to ENT to take biopsy of mouth to determine if I have Sjogren's Syndrome. November 29-December 6 dizzy, lightheaded, joint pain and fatigue. Friday, December 9 Extremely dizzy, very fatigue moved very slowly. Saturday, December 10 Very fatigue joint tenderness in knuckles, wrists, left shoulder I could hardly walk very tired and slowed down. Motor coordination very weak. Sunday, December 11 very tired and laid on couch most of the day no energy. Monday, December 12 Still very tired and laid around joint pain. Tuesday, December 13 Went to see ENT Dr. consult. Wednesday, December 14 Dr. did lip biopsy had to put 2-3 stitches on left side of mouth and took skin from right side too. I felt lightheaded, no energy tired joint pain throughout body. Friday December 16 2:00 pm driving to back; had difficulty breathing nose numb, shortness of breath lasted two hours almost had to pull over and call EMS left shoulder tingly, weak knees, ankles, knuckles, wrist, all joint areas very painful. December 17-21 Very fatigue, joint pain, knuckles pain in the center of my palm. December 22 Going back to ENT to get results of lip biopsy; extreme fatigue, pain in joints especially knuckles and hands cramping wrists. Jan. 3 3rd MRI. Jan. 4 GI follow up visit for esophagitis. Jan. 5 Dr. rheumatologist follow up. Feb. 6 follow up with neurologist Dr. from 3rd MRI.