Age: 0.2
Sex: M
Vaccine: DTAP, HEP, HIBV, IPV, DTAP, HEP, HIBV, IPV
Symptoms: Retinal haemorrhage, Subdural haematoma, Vomiting
Clinical narrative: Sometime after the vaccinations the pt experienced seizures and strokes. The pt is currently hospitalized with intracranial bleeding and retinal bleeding. No specifics were provided. Further information is being requested. Follow-up received on 3/1/01 noted "No problems until 11/00" by MD. Additional info regarding pt, vaccine administrator, responsible physician, reporter, date of vax and vaccines given were provided. As you know, the pt was hospitalized for a reported acute head injury on 12/29/00 and I first examined him and followed his medical care there for a little more than a week or so. I have interviewed and spoken with the parents on numerous occasions since and seen and examined the pt several times. I have reviewed all tests and exams and an exhaustive medical evaluation is now complete. After many MRI's and exams, the mother disclosed that the infant had fallen off of a couch. The baby was discharged on low-dose baby aspirin (1/4), Zantac and seizure free on phenobarbital to be mixed into 2 bottles per day. The type of stroke injury seen on the scans is 'non-hemorrhagic' or ischemic. After the fall, the pt was unresponsive and EMS was called. In PICU the areas of pre-existing permanent brain damage were again seen in the pt's brain, but also a large right subdural hematoma and bilateral retinal hemorrhages were first discovered. These were not present in November. A new skeletal survey was still nml. The pt required neurosurgery on 1/2/01, to release the pressure on his brain. At surgery, the right subdural was seen to be made of blood, fluid and membranes, which is in agreement with the CT scans prior to surgery that documented new, subacute and older blood in the right subdural. This subdural hemorrhage(s) of various ages likely explains the history of intermittent vomiting during the 10 or so days prior to 12/29/00, which then became accompanied by recurrent seizures in spite of phenobarbital prior to the neurosurgery and the improvement in both the vomiting and the seizures after the subdural was evacuated. He has now been in foster care without known new events. This baby has suffered abusive head trauma or 'Shaken Baby Syndrome'. There were bilateral retinal hemorrhages and also a large retinal hemorrhage in the right macula that is usually seen in severe infant head trauma cases. A low-height fall from a couch to a carpeted floor cannot cause these and there is no other dx for this combination of medical findings than violent head trauma. I have considered aspirin as a complicating factor in the case. His PT and PTT were normal. While aspirin cannot be 100% ruled out as at least a contributor to continued bleeding after intial head trauma, it could have caused the subdural to become larger than it otherwise might have become, physical forces must have 1st injured the blood vessels to allow the blood to leak into the space in the 1st place. These same physical forces must also have caused the retinal hemorrhages at the back of both eyes and the same violent physical forces are certainly the cause of the retinoschisis.