Age: 62.0
Sex: M
Vaccine: LYME
Symptoms: Back pain, Borrelia burgdorferi serology, Borrelia burgdorferi serology positive, Burning sensation, Cognitive disorder
Clinical narrative: This case was reported by a lawyer and described the occurrence of joint pain in a male subject of unspecified age who was vaccinated with LYMERIX (GlaxoSmithKline). A physician or other health care professional has not verified this report. The subject's medical history, concurrent conditions and concurrent medications were not reported. On an unspecified date the subject received unspecified dose of LYMERIX (unknown). An unknown amount of time after vaccination with LYMERIX, the subject experienced joint pain, flu-like symptoms, autoimmune disease, activities of daily living impaired, memory loss, headache, joint stiffness, tingling of extremity, rheumatological symptoms, neurological impairment and cognitive impairment. At the time of reporting the outcome of the events was unspecified. This information was received via a Statement of Injuries. Follow up information was received on 16 January 2009 via information resulting from an interview between the subject and attorney (s). The subject received the first and second doses of LYMERIX both in October 1999, approximately one week apart, and the third dose of LYMERIX in October 2000. From six months to one year after the second dose of LYMERIX, in 2000, the subject developed hand pain/burning/stiffness, and flu-like symptoms. Treatment included PREDNISONE, HYDROCHLOROQUINE, METHOTREXATE, ALEVE, and unspecified medications and injections. The events were unresolved at the time of this report. Follow up information was received on 08 April 2009 via medical records. The subject received the first and second doses of LYMERIX on 25 October 1999 and 24 November 1999. The subject was reportedly well until he received LYMERIX in October 1999. On 29 June 2000, he was involved in a motor vehicle accident without head trauma or loss of consciousness. He was referred to orthopedists and complained of right shoulder and low back pain, as well as anterior thigh pain with walking. He received transient relief with a lumbar epidural and physical therapy. In October 2001, the subject developed pain in the right hand that subsequently affected both hands, as well as increasing morning stiffness. The subject was evaluated by a rheumatologist and was diagnosed with osteoarthritis of the hands and spinal stenosis on unspecified dates. On 16 July 2002, the subject underwent an surgical decompression at L3/4 and L4/5 for spinal stenosis and excision of herniated disc. The subject was evaluated by a neurologist on 20 March 2003 due to complaints including low back soreness after sitting, thigh pain, and numbness in calves. Neurologist's opinion was that the subject injured his low back as a result of the June 2000 motor vehicle accident. Examination was notable for motor neuron findings of lower limb hyperreflexia with a probable right Babinski, possibly representing cervical myelopathy. On 08 April 2003, magnetic resonance imaging of the brain showed several small nonspecific white matter signal abnormality consistent with microvascular angiopathy. A physician's note dated 03 March 2006 indicated that the subject had rehumatological disease versus Lyme, and that the subject was status post Lyme vaccine. Complaints between March 2006 and June 2008 included increasing stiffness, finger pain and numbness, shoulder pain and stiffness, trigger finger, numbness and stiffness of the hands. Treatment included PREDNISONE.