Age: 3.0
Sex: F
Vaccine: MMR
Symptoms: Convulsion, Dyskinesia, Hyperhidrosis, Tremor
Clinical narrative: Information has been received from an RN concerning a 3 year old female pt who on 7/17/01, was vaccinated with MMRII. The RN reported than since 8/17/01, her daughter has experienced seizure-like activity on a daily basis. She stated that she has seen everything from a flexing of the toes (almost daily) to a full grand mal seizure. At the time of this report, the pt had not sought medical attention. Upon internal review it has been determined that the grand mal seizure was an "Other Important Medical Event". Additional information has been requested. F/U states the lot number as 634321/1384K and there were no concomitant therapy. An RN in the NP's office, reported that the pt had had previous immunizations with no problems. On 8/18/01, the pt's mother called the office 3 separate times reporting that her baby-sitter has been reporting to her for the past 2 weeks, that the pt has been displaying various shaking of different parts of the body. She remained alert and awake and "looking all around". The 8/18/01 date was the 1st time that the mother had witnessed this while giving the pt a bath. The mother took the pt to a hospital and waited for 2 hours to be seen. The mother noted that nothing was done in the ER. The ER physicians dx'd the pt with seizures and told the mother that her daughter needed to be seen by a pediatric neurologist and have an EEG done. On 8/20/01, the pt's mother called the office to request a referral to the pediatric neurologist for an EEG and a CT Scan. At the time of this report, a pediatric neurologist was currently following the pt. F/U info has been received from a physician which indicated that the child was seen on 9/11/01 by a pediatric neurologist whose impression of the pt was reported as "abnormal movements" that did "not appear to be seizures". Additional info received from an NP confirmed that the child was "not having seizures". No further info was provided. F/U information received from an NP on 11/6/01 indicated that the dose of MMRII noted in this report was the pt's 2nd dose. It was noted that "given the combination of events", the pediatric neurologist planned to do a 24-hour video EEG. Upon internal review, "abnormal movements" was determined to be an "Other Important Medicat Event". Additional information has been requested. Follow up information received from the nurse practitioner indicated that the patient also developed abnormal movements of her face and a tightening of her muscles occurring up to 10 times a day. It was noted that the patient had not experienced any other adverse events following previous vaccination. She noted that a diagnosis of dystonia vs. benign Rolandic epilepsy was proposed. Medical records received from a neurologic evaluation of the patient on 11/19/01 indicated that the patient was referred for an evaluation of possible seizures, and that it was the patient's first neurological consultation in the neurology clinic. The patient, who was on no medication presented with a six month history of episodic intermittent abnormal muscular movements most often in the legs, which someimes involved the arms or the face with muscle contractions. It was reported that the patient in general has been a very healthy child. She was growing and thrivign and her development had been outstanding. It was noted that her movements tend not to happen with exercise or stimuli, and that it tends to happen more often with similar events such as watching TV. It has increased in frequency of the last few months, and now occurs up to 10 times per day. It lasts five to ten seconds, but can last up to 2 to 5 minutes on rare occasion. During the longer events, the patient may become sweaty, and generally does not have loss of consciousness. The patient's father described some events involving the patient's jaw and noted that it was like someone else moving her jaw. During these events, the patient sometimes had her eyes up, and those were the events that lasted somewhat longer. The patient was reported to have excellent athletic abilities and is very verbal. She had not lost any skills and overall did not seem to be too disturbed by this whole process. It was noted that the patient was the product of full-term gestation, there were no birth complications. Apgar scores were normal, and no jaundice, infections or other significant problems were observed. Her early childhood history indicated that no major problems were identified and she had no past surgeries. The patient obtained all of her developmental milestones appropriately and on time. Both of the patients parents and sister are healthy, and there are no known neurologic developmental disorders in the family. There are also no major social history problems. A physical examination indicated that the child was well nourished, well hydrated and had no acute distress. All other general physical exam findings were normal. Results of a neurological exam showed that the patient was alert and oriented to place and persons and that her mood appeared normal. No signs of excessive anxiety or agitation were noted, and her developmental receptive and expressive language skills appropriate for her age level. All cranial nerve and musculoskeletal tests performed were normal. The patient was assessed as having increasing paroxysms consistent with episodic dystonia or possible subtle seizures. The etiologic diagnosis reported that those events were of uncertain etiology and significance, characterized by intermittent muscular movements, most consistent with dystonia and most often involving the patient's legs but sometimes the arm and face. There was minimal change in consciousness and minor EEG changes. The neurologic diagnosis reported general normal growth development and neurologic function with no major neurologic processes or metabolic disturbances. It was noted that htere is an ongoing consideration of seizures and dystonia. The medical diagnosis indicated that no major medical problems were identified. Medical records received from a prolonged video recording with prolonged outpatient awake/asleep EEG performed on 11/19/01 indicated that the patient had a history of normal standard EEG in the past. It was noted that the prolonged EEG was requested to evaluate for epileptiform discharges. It was reported that the EEG performed over approximately 1.5 hours was abnormal because of periodic spike-like sharp transient occasionally isolated in the right central regions of the brain, but also occurring independently over other head regions. The clinical correlation indicated that the EEG was consistent with a mild diffuse disturbance of brain function and posibly consistent with a seizure disorder. Clinical correlation was advised. The physician who assessed the patient noted that there were a number of subtle abnormalites in the EEG. Many of the spikes were isolated or occurred following slow waves. Some spikes had positive and some had negative polarity. Occasionally sharp waves were seen over the frontal and posterior regions as well. No clinical changes were observed during the EEG. The physician noted that the events themselves; however, were more typical for dystonic posturing. Two events were observed on the EEG in which there was toe curling. In addition there were some plantar flexion posturing of the legs. During this, the patient almost appeared to flex her legs and cross her legs to break the pattern. The physiican felt that even more concerning; however, was the description by the patient's father about the jaw movements. He felt that this type of system could be more typical for benign rolandic epilepsy of childhood with central temporal spikes. He noted that in this condition, there are often times oropharyngeal or facial manifestations that include involuntary movements or tonic fracntions of the jaw. He reported that management options at this time would include a diagnostic trial of medications. Consideration of a two to three week course of low dose carbidopa 25/ levodopa 100mg tabs given as one quarter tablet bid for the first week, and one quarter tablid bid for the second week and doses up to one half tablet bid in the third week depending on the patient's response were proposed. Consideration of an anti-epileptic drug therapy trial was also proposed if the episodes perisited after the levodopa trial. Further observation of the patient for the time being was also planned. The patient's parents elected at this tiem to consider their options and to observe clinically for a greater period of time. The patient's parents felt that the patient's episodes were related to the therapy with MMR (second generation). Upon internal review, abormal EEg, episodic dystonia/intermittent muscular movements, seizure disorder and abnormal jaw movements were determined to be other important medical events. Additional information has been requested. Follow up indicated that as of 2/12/02 the reporter has not had further contact with the patient. There is no new diagnosis or additional information. No further information is available.