Age: 71.0
Sex: F
Vaccine: TD, TTOX
Symptoms: Urinary tract infection, Urine analysis normal, Vaccination complication, Vertigo, Vitamin B12 deficiency
Clinical narrative: Nausea, vomiting, myalgia, extreme muscle weakness, could not get out of bed, dizzy, chest discomfort, significant neurologic complaints. MR received from PCP which included H&P consult with Neurologist and hospital d/c summary from 10/14/2006. Medical records indicate that beginning 9/26/06, the evening of pt's Td vax, she developed flu-like symptoms including fever (100.4F), nausea, vertigo, full body myalgias, muscle heaviness and weakness, muscular chest discomfort, and sweats. She vomited on 9/28/06.  She made the first call to her MD on 9/29/06, where it was felt she may be having a reaction to Cipro which she was prescribed for a UTI on the day of her vax. Antibiotic was change to Levaquin and Phenergan rx'd for nausea.  Office visit 9/30/06 with c/o fevers, sweats, nausea, pain, feeling unwell and lacking energy. Antibiotic changed to Doxycycline  with no improvement.  Mildly slurred speech and cognitive changes were noted by daughter at this time as well as her mother's desire to sleep all of the time, and lack of participation in normal ADLs. Patient continued to decline, resulting in another office visit to PCP on 10/04/06 with c/o dizziness, fatigue, and myalgias.  On 10/05/06 pt reports feeling a little better in TC to MD.  10/10/06 Patient reports to MD that feels she may have had a rxn. to her Td vax. and requests referral to neurolgist. Patient also reports weight gain despite lack of adequate intake, due to fatigue. Office visit to PCP 10/11/06 with c/o weakness, dizziness, myalgias, and chest discomfort, somewhat improved over last week, but persisting. MD suggests "probable reaction to Td vaccine, progressing slowly". Neurolgy consultation on 10/12/06 assessed generalized weakness, gait ataxia, worsening fatigue, and resulted in an overnight hospital admission for further evaluation.   Primary D/C DX: read "reaction to tetanus shot".   F/U visit to PCP on 10/23/06 revealed continued weakness and inability to use R hand as well as prior to vax.  Assessment: "Adverse rxn. to Td vaccine, improving slowly". Information received from the annual follow up that patient has not recovered. My energy level still has not returned to the level it was on Sept. 25 2006. I suffered more pain in the six to seven months after the shot than anyone will ever know and I would be so thankful if my life as I knew it before that day would return. I still cannot do the things that I did then. It makes me very upset to even think about what this shot caused me. Per 60 day follow up: Continues to have difficulty using arms. Feels weak & tired. Per 60 day follow up: I still have muscle weakness in my right arm. Also I have certain movements that I can't do. When I fuse my right hand very much, it goes numb. (Example: Since I started writting this, my hand has drawn in. Cannot lift more than 8 cups of coffee with one hand. Energy has never returned as it was before 9/26/07. People should not be given Tetanus unless there is a known need. My life has changed so very much from this. My days should be enjoyed as I grow older and this shot has taken that from me. Some days I am very angery over this. Also I think of babies that can't tell anyone how sick they are after they are given this shot.