Age: 50.0
Sex: M
Vaccine: FLUX
Symptoms: Clinically isolated syndrome, Coagulation test normal, Computerised tomogram head normal, Coordination abnormal, Demyelination
Clinical narrative: Case number PHHY2015US003545, is an initial spontaneous report received from Vaccine Adverse Event Reporting System (the source of the case in VAERS is a literature publication, VAERS reference number: 548463) website on 06 Jan 2015. This report refers to a 50-year-old male patient. The patient's concurrent conditions included hypothyroidism, hyperlipidemia, gastroesophageal reflux disease, psoriasis, attention deficit/hyperactivity disorder and depression. The patient was allergic to penicillin. Past medical history included right-handed supraclavicular phrenic nerve lipoma which was removed in 2007. Past surgical history included hernia repair, appendectomy, knee arthroscopy, tonsillectomy and excision of the aforementioned lipoma. Patient's family history included hypertension and heart disease within the maternal lineage and a sister with anemia. The patient was a former smoker of 1 pack per day for 3 years (successfully quitting in 1983). The patient also reported occasional alcohol intake and no recreational drug use. The patient's concomitant medications include levothyroxine, dexlansoprazole, clotrimazole/betamethasone cream, methylphenidate, and alprazolam. He was vaccinated with seasonal influenza vaccine (manufacturer unknown, batch number: not reported) on an unknown date. On an unknown date, one day after the vaccination, the patient experienced acute central nervous system (CNS) demyelinating episode secondary to vaccination (either clinically isolated syndrome (CIS) or acute disseminated encephalomyelitis (ADEM)). The episode was progressive, focal and had neurologic deficits. The patient had left-sided weakness, left arm was weak, numb and the full left arm had paresthesia. The patient had blurred vision in the left eye, itchy sensation on the entire left side of the face. Neurologic examination revealed slight facial asymmetry on tests for cranial nerves 5 and 7. The remaining cranial nerves were grossly normal. Motor testing showed the patient's arm and leg were weak (3/5) and the patient had a left-sided drift. Tone was increased on the left and coordination was slightly diminished on the left compared to the right with rapidly alternating movement. No tremor or ataxia was noted. Sensation to pain, temperature, and vibration was intact. Reflexes were three plus on the left and two plus on the right with down-going toes bilaterally. On an unspecified date, the patient was hospitalized. Laboratory investigations are as follows: results of comprehensive metabolic panel, coagulation studies, and complete blood count were all within normal limits. LDL (low-density lipoprotein) and triglycerides were elevated at 106 mg/dL and 193 mg/dL respectively. The full evaluative course of the patient was extensive and initially focused on a working diagnosis of acute stroke. A chest x-ray, performed on admission was unremarkable. Computed tomography (CT) of the head without contrast did not reveal any space occupying lesion; intracranial hemorrhage; hydrocephalus or shifting of the ventricles. Evidence of cerebral infarction or edema was non-existent. Similarly CT angiography of the head and neck and bilateral carotid was unremarkable. The final outcome of the events was unknown. The reporter stated that this report would serve as a document of a case for CNS demyelination occurring 24 h after influenza vaccination in a middle-aged patient and described some of the salient features regarding the differential diagnosis of CIS and ADEM.