Age: 38.0
Sex: M
Vaccine: LYME
Symptoms: Arthralgia, Headache, Hypokinesia, Influenza like illness, Neck pain
Clinical narrative: In 3/99, the pt received his first dose of Lymerix for prevention of Lyme disease. Subsequently, he experienced neck pain and shoulder pain. Symptoms resolved in three days. In April, 1999, the pt received his second dose of Lymerix. Subsequently, he experienced flu-like symptoms and his kneecaps hurt. The symptoms resolved after one week. In May, 1999, the pt received his third dose of Lymerix. Subsequently, he experienced elbow, shoulder, neck pain and developed a headache. the pt could "hardly move". Outcome is stated as ongoing. The most recent information received on 7/19/99, reports the condition of the pt as ongoing. A 15-day follow up report received 2/15/2001 adds: This report was received from the pt's wife and a lawyer and has not been verified by a physician or other health care provider. Reportedly the pt has no allergies or relevant medical history. The pt takes alpratolam (Xanax), sertraline hydrochloride (Zoloft), and nambumatone (Relofen). He denies a history of Lyme disease. On 03/03/1995 the pt received his first dose of Lymerix for prophylaxis of Lyme disease. Almost immediately post-vaccination, he experienced severe flu-like symptoms which lasted 3-4 days, and which were recorded by his vaccinating physician on 04/13/1999 as "head cold, lung, nose" and diagnosed as an upper respiratory infection. On 04/28/1999 the pt received his second dose of Lymerix. On 04/29/1999 the pt experienced "extreme" pain in his joints and muscles (including neck, kneecap and shoulder pain) and became very stiff. The pain and stiffness left the pt confined to bed for a full week, during which he described himself as being "basically crippled". The following week he could begin to walk a little. His symptoms lessened somewhat by 06/09/1999. On 06/09/1999 the pt received his third dose of Lymerix. Subsequently, he experienced elbow, shoulder, neck pain and developed a headache. He experienced all the symptoms he had experienced after the second vaccination to a greater extent. The pt could "hardly move". As of 02/01/2000 the pt reportedly continues to suffer from joint pain, back pain and headaches to such an extent that he has been forced to stop working. This report is considered serious since the pt was disabled and could not work. A 15-day follow up report received 01/28/2002 adds: Report 19990186860-1 describes reactive spondyloarthropathy in a 38-year-old male who received Lyme disease vaccine recombinant OspA (Lymerix). This report was received from the pt's wife and a lawyer, with forwarding of medical records. The pt's wife reported that the pt had no allergies or relevant medical history. The pt denied a history of Lyme disease. Review of medical records indicated that the medical history included anxiety, depression, an "episode of stress", "binge" alcohol use, marijuana use, liver dysfunction, hypercholesterolemia, life-long resting nystagmus, and carpal tunnel syndrome. Concurrent medications included alprazolam (Xanax), huspirone (BusPar) sertraline hydrochloride (Zoloft), and niacin. On 03/09/1999 the pt received his 1st injection of Lymerix for prophylaxis of Lyme disease. Almost immediately post-vaccination, he reportedly experienced "severe" flu-like symptoms and general achiness which lasted 3-4 days, and which were allegedly recorded by his vaccinating physician on 04/13/1999 as "head cold, Lung, nose". The vaccine provider allegedly made a diagnosis of upper respiratory infection. On 04/28/1999, the pt received his 2nd injection of Lymerix. On 04/29/1999 the pt reportedly experienced "extreme" pain in his joints and muscles (including neck, kneecap and shoulder pain) and became very stiff. The pain and stiffness left the pt allegedly confined to bed for a full week, during which he described himself as being "basically crippled". The following week, he could begin to walk a little. His symptoms seemed to have resolved by early June 1999. On 06/09/1999 the pt received his 3rd injection of Lymerix, this was 3 months, rather than the recommended 12 months, following receipt of the 1st Lymerix injection. Subsequently, he reportedly experienced pain in the elbow, shoulder and neck and he developed a headache. Additionally, he reportedly experienced achiness and stiffness. He experienced all the symptoms he had experienced after the 2nd vaccination to a greater extent. The pt could "hardly move". On 06/16/1999 the physician allegedly made a diagnosis of "reaction to Lyme vaccine" and prescribed hydrocortisone (Cortizone). The following info was obtained from medical records. The pt received his 1st injection of Lymerix on 03/09/1999. He was seen by the vaccine provider on 03/17/1999 to follow up on previously scheduled diagnostic evaluations. The pt did not report any adverse events at this office visit. On 04/13/1999 the pt saw the physician with complaints of head cold and runny nose. The physician noted nasal discharge on physical examination and made a diagnosis of upper respiratory infection. The physician prescribed amoxicillin clavulanate (Augmentin). The pt received his 2nd injection of Lymerix on 04/28/1999. Prior to receiving the injection, "pt states after Lymerix shot...he felt pain in joints, muscle ache. Pt states he felt very stiff." The pt was seen by the vaccine provider on 05/10/1999 and 06/01/1999 due to depression, mood swings and anxiety. No adverse events were reported during those office visits. The pt received his 3rd injection of Lymerix on 06/09/1999. At that time, he did not report any adverse events following receipt of the 2nd injection of Lymerix. The pt saw the vaccine provider on 06/16/1999 with a chief complaint of "being stiff after getting Lymerix shot." The physician noted that achy back pain began 4 days following receipt of the 3rd Lymerix injection. Physical examination was "normal". The physician made a diagnosis of "Reaction to Lyme vaccine" and prescribed Ibuprofen (Advil). The pt was seen again on 06/17/1999. Physical examinationn was normal. The physician made a diagnosis of "Allergic reaction to Lyme vaccine? Arthritis syndrome?" He prescribed a 5-day course of prednisone, and instructed the pt to return to the office in 7 days. The pt returned on 06/30/1999. Physical examination was normal; no complaints were recorded. A diagnosis of elevated cholesterol was made, and the physician prescribed niacin. On 07/07/1999, the pt presented to the vaccine provider with chief complaints of "joint pain, back pain, also complained of headache for 3 to 4 weeks (since Lyme vaccine). Pt comments all symptoms after 2nd and 3rd shot." The pt also complained of "sleepiness". The physician made a diagnosis of "Arthralgia" and prescribed nabumetone (Relafen) 500 mg twice daily. The pt was seen again on 07/10/1999. A diagnosis of "Myalgia" was made and Relafen therapy was discontinued. The pt returned to the vaccine provider on 07/20/1999. Reason for the visit was recorded as "Pt here for joint pain, back pain, also complains of headaches. Thinks it may be Lymes (sic) disease." The physician noted that the pt experienced relief with Relafen. A diagnosis of "Polyarthralgias" was made and the physician prescribed Relafen 750 mg twice daily. On 08/19/1999, erythrocyte sedimentation rate (ESR) was 7 mm/hr. The pt was referred to a rheumatologist at a tertiary care center. The pt was seen by the rheumatologist on 09/09/1999. At that time the pt "presents with a 4 month history of stiffness and pain in the neck, back and knees...He dates this to having received the Lyme vaccine his 2nd dose in May when at that time he developed weakness, fatigue, malaise and stiffness in both hands. These symptoms resolved but restarted again when he received the 3rd injection. Since then, he developed a waxing and waning patterning of joint pain predominantly in the neck and back, although he states the knees have been involved at some point. He has never had any hot, red, swollen joints and the stiffness improves with activity. He has difficulty sleeping at night because of the pain. He denies morning stiffness." Medications at the time of the evaluation included alprazolam 0.25 mg twice daily, Relafen 750 mg twice daily, orphenadrine 100 mg twice daily and sertraline 50 mg daily. "He drinks occasionally and admits to marijuana use." On physical examination, "there was no tenderness on spinal exam but he had decreased range of motion particularly with flexion and some muscle spasm. He had limited range of motion of his shoulders secondary to pain. No sacroiliac joint tenderness was noted. The rest of the joints were within normal limits." The rheumatologist wrote, "My impression is that the pt has mostly muscular pain of the low back and around the shoulders. We cannot completely exclude a diagnosis of ankylosing spondylitis or reactive arthritis, though I think it is unlikely. Arthralgias have been described after the Lyme vaccine but as I mentioned to the pt, it would be difficult to tell if it is related...He had disability papers which I initially suggested were difficult for me to complete with evaluation on just one visit, and that stating a date for him to return to work was not possible and that symptoms resolve with time. I did complete the diagnosis of low back pain...I am also concerned that the pt has repeated on several occasions (both in person and by telephone) to me that he blames all current symptoms on the Lyme vaccine and he is upset that no one will accept this. Discussion of this has been extensive, specifically that there is no test to confirm this and that he should work on current pain relief and physical therapy to improve current pain, but it is difficult to get past this issue." The rheumatologist recommended celecoxib (Celebrex) 200 mg once or twice daily, tramadol (Ultram) 50 to 100 mg daily at bedtime, and physical therapy. She referred the pt back to his primary physician regarding disability, X-ray of the sacroiliac joints, performed on 09/09/1999, was "Negative". X-ray of the cervical spine, performed on 09/11/1999 was "Negative". Results of an X-ray of the lumbar spine, performed 09/13/1999 were reported as "Negative. Note L4 'limbus vertebrae'-unfused ossification center." On 09/05/1999 C-reactive protein was <1.0 mg/L. A test for the HLA-B27 antigen was positive on 09/09/1999. The pt began physical therapy. The physical therapist notified the rheumatologist of the pt's progress on 10/11/1999. The physical therapist wrote, "(The pt) is being followed in Physical Therapy 3 times weekly with the diagnosis of OA (osteoarthritis) of C/SP (cervical spine) and Fibromyalgia. His treatment protocol consists of Anti-inflammatory modalities; Myofascial Release, Therapeutic Exercise and Kinetic Exercise. As of today pt still has complaints of intermittent pain, stiffness and discomfort over his neck, middle back and lower back, but much better than before. Pt also notes that he stiffens up especially in the morning whenever he missed his medications. Pt rates pain to be about 4/10." On 11/29/1999, antinuclear antibody (ANA) titer and rheumatoid factor were negative. C-reactive protein was <5.0 mg/L. Lyme antibody screen was positive, but Lyme IgM and IgG Western blot analyses were negative. ESR was 1 mm/hr. Radionuclide whole body bone imaging was performed on 12/07/1999. The radiologist's impression was "Normal whole body bone imaging. Solitary focus increased uptake left foot incidentally noted, consistent with previous trauma or degenerative disease." The pt was seen by another rheumatologist on 12/28/1999. The rheumatologist wrote, "After the first 2 injections (of Lymerix), he recalls, developing myalgias and arthralgias especially of the spine. He recalls that back spasms would start with severe fatigue and myalgias. Eventually his hand became clawed and he was not able to extend his fingers. This became worse after the 2nd injection and after the 3rd one, it took 5 days and he actually thought he was going to bypass it, at that time, but by the 5th day he had the same fatigue, myalgias and clawed hand...He does have episodes of hot and cold sweats he even gets intermittently at this time, although much more infrequently than over the summer. He never has warm or swollen joints...He has episodes of involuntary kicking of his legs and knee shaking that will last for hours at a time, which now only occurs every few weeks. During the summer months this would occur a few times each week. He has had carpal tunnel for years and sometimes will awaken with his hands sleeping and his elbows bent. He recalls an episode of stress, 2 years ago, for which he was on Xanax and he is currently on Xanax again, 0.5 mg, bid and he has also been on Zoloft for the past few months. He has been on disability since September. He has been a binge drinker in the past, but does not consider himself to be a drinker. He has morning stiffness, at least 2 hours, each day. The pain is severe intermittently and recalls having about 4 days of no pain in September, but the pain did come back. On physical examination, "He is not able to rotate his neck fully and lacks at least 15 degrees of rotation. When he flexes his neck he has pain at C6-7 going up to the occiput. Extending he has pain in the C6-7 into the trapezius. He was able to touch, initially, only 14 inches to the floor, but the Schroeber sign is 6 cm. At follow up he was able to touch 6 inches to the floor with pain mostly in the thoracic spine. Chest expansion 5 cm, lateral rotation 2 cm. Knee and hip have full range of motion, with effusion. Right hand squeezes 60 pounds, left hand 40 pounds. Slight pain in the PIPs (proximal interphalangeals). Again, no warm swollen joints. Initially he had a trigger point of his trapezius and buttocks, but, at this point, there are actually no trigger points." The rheumatologist wrote, "we must consider the Lymerix vaccine to be an immune stimulant in this case, causing what appears to be a form frust of reactive spondyloarthropathy." The rheumatologist recommended celecoxib, tolmetin (Tolectin DS) and possibly sulfasalazine (Azulfidine). The pt saw the 2nd rheumatologist again on 01/15/2000 and reported finding blood in his stool. The pt stopped taking Celebrex and Azulfidine. The rheumatologist noted increased arm weakness. The rheumatologist discontinued Azulfidine therapy. On an unspecified date, the rheumatologist prescribed rofecoxib (Vioxx). In an office note dated 03/15/2000, the 2nd rheumatologist noted that the pt had been seen by another physician, who reportedly specializes in "emerging diseases". Pharmacy records indicated that this physician had prescribed Clarithomycin (Biaxin), cefuroxine (Ceftin), cefixine (Suprax), azithromycin (Zithromax), carisoprodol, dextropropoxyphene/paracetamol (Darvocet N-100), celecoxib (Celebrex), tramadol (Ultram), alprazolam (Xanax), zertraline (Zoloft) and buspirone (BusPar) between 04/11/2000 and 12/10/2001. ESR was 3 mm/hr on 03/16/2000. Unspecified testing for HLA-DRs was negative on 03/16/2000. The most recent info was received on 01/11/2002. As of 03/21/2001 the pt reportedly continued to suffer from joint pain, back pain, achiness, stiffness and headaches to such an extent that he had been forced to stop working since June 1999. Therefore, the pt is considered to be disabled. A 15-day follow up report received 6/11/2002 adds: The most recent info, received on 5/28/2002 did not provide the outome of the reported events. Info received on 03/22/2002 indicated that the pt was feeling "better" as of 02/18/2002. As of that date, he was still receiving treatment for Lyme disease. Outcomes of the other reported events were not provided. The pt was reportedly unable to work from June 1999 until at least 03/21/2001. Therefore the pt is considered to be disabled. A 15-day follow up report received 6/17/2002 adds no new info.  Follow up on 02/20/2002: "The vaccinee returned to the rheumatologist on 10/04/1999 "with further complaints of low back pain, neck pain, muscle tenderness and cramps."  Medication at that time included orphenadrine 100mg twice daily, tramadol 100mg at bedtime, celecohib 200mg twice daily, and a tapering dosage of alprasolam.  The rheumatologist wrote, "on examination on 10/04/1999 I was still at a loss to give a definitive diagnosis on this patient.  He does have some muscle tenderness by the right scapular worse on motion of his arm.  He has decreased range of motion of his back and pain on flexion of his back but no sacroiliac joint tenderness, no neurological deficit and good range of motion of the knees although he says they are painful when he gets up from a chair....I have suggested to him that I do not think he has an inflammatory component to his pains at the moment....I think this is mostly muscular associated with the cramps.  There is a question of muscular cramps and stiffness I have suggested that he possibly see a neurologist....I do feel he may have a fibromyalgia component to his symptoms particuarly with the slpp disturbance and have suggested he increase the Ultran to two (200mg) twice a day and that the Norflex should help with the fibromyalgia.  I have also suggested he go to a pain specialist who might be able to give him trigger point injections.  He is continuing with physical therapy, which he has had two visits.  The follow up received on 2/25/02 states cocaine use, left knee injuryk and "mild" obstructive lung disease. The vaccinee received his second injection of LYMErix on 4/28/99. Prior to receiving the injection, "pt states after LYMErix shot he felt pain in joints, muscle ache. Pt states he felt very stiff." The vaccinee was seen by the vaccine provider o 5/10/99 and 6/1/99 due to depression, mood sweings, and anxiety. No adverse events were reported during those office visits. The vaccinee was referred to a psychologist on 5/14/99 "for help in dealing with the anxiety attacks he has been experiencing over the past several weeks. The psychologist noted that the vaccine "was immediately able to anchor his anxiety in concerns about his job. He unashamedly indicated that he used to take a lot of pride in his work; however, certain poitical union and personal issues have occurred over the past several years which ha smade his job less attractive and according to him, the source of a lot of his stress. He still tried hard to do a good job but encounters a lot of obstacles and it is this interface that seems to be behind his anxiety. This iss further reinforced by the idea that in addition to his job he also has his own business as a landscaper, his other job. As we worked during our first session he was able to see that it is really his attitude more than job variables that determine how anxious he will become. In other words, he doesn't mediate stress well and this usually turns to anxiety. He is experimenting with trying to get a buy out of his job, trying to find other employment although these may be dead end quests" due to his current salary and number of years of experience in his current job. The vaccinee was to continue individual therapy. On 6/16/99, the erythrocyte sed rate was 4mm/hr. The most recent info, received on 2/25/02, did not provide the outcome of the reported events. Info received on 2/23/02 indicated that, as of 3/21/01. the vaccinee reportedly continued to suffer from joint pain, back pain, achiness, stiffness, and headaches to such an extent that he had been forced to stop working since June 1999. Therefore, the vaccinee is considered to be disabled. The follow up received on 3/22/02 states that in an office note dated 3/15/00, the third rheumatologist noted tha the vaccinee had been seen by another physician, who reportedly specializes in "emerging disesase." Medical records from that physician indicated that the initial assessment was made on 3/27/00. The vaccinee reported that after the first injection of LYMErix, he experienced "stiff neck and shoulder bilaterally." After the second injection of LYMErix, he reproted that he became "crippled up; back stiff." These events reportedly persisted for two weeks. Four days after the third injection of LYMErix, the vaccinee reported that he experienced "arthritis; spine pain; stiff; hands clawed, knees cannot bend." Medications at the time of evaluation inlcueed sertraline 50mg daily, alprasolam 0.25mg daily, rofecoxib 25mg dily and tramadol 50mg  "sometimes." On physical examination, the physician noted swollen lide and extremities. The physician's impression was "Lyme or vaccine induced Lyme." Lyme IgM Western blot was positive, demonstrating 23, 38 and 41 kD bands. Lyme IgG Western blot was also positive, demonstrating 28, 30, 45, 58, 60, 66 and 93 kD bands. The vaccinee returned to this specialist on 4/8/00 with chief complaitns of "joint pain; feels like broken glass; hands hurt; affected by noise; confused; Celebrex caused edema; muscles hurt and feel stiff." He also reported SOB, blurred vision, and memory loss. Medications included sertraline 50mg daily, tramadol 50mg "on and off" and rofecoxib 25mg daily. On physical examination, the vaccinee appeared anxious. Under "hearing,: the specialist checked "normal" and "tinnitus." The specialist noted edema of the hands; decreased range of motion of hte cervical spine, thoracic spine and lumbosacral spine; decreased muscle strength; and decreased joint swelling. The specialist noted the positive Lyme IgM and IgG Western blots. The specialist made a diagnosis of "Lyme disease probably exacerbated by vaccine" and prescribed Biaxin 500mg twice daily, Ceftin 500mg twice daily, Soma "for muscle relaxation," and Dervocet N-100 "if pain is too bad at night." The vaccinee returned to this physician on 6/19/00, reporting "spray bottle sound." He also reported "tingling lips;  not working; still weak; pain not as constant; able to walk now; other symptoms unchanged." The diagnosis was recorded as "antibiotic resistant Lyme disease." On 7/24/00, the vaccinee reported that "after stopping antibiotics for five days felt much worse." On physical examination, the physician noted nasal congestion, vertigo, and palpitations. The diagnosis was recorded as "Lyme" and the physician prescribed clarithromycin 300mg twice daily. On 8/21/00, the vaccinee reported "more symptoms after eating yeast and sugar." The physician noted edema of the legs as well as decreased range of motion of hte legs. Clarithromycin therapy was continued. On 10/2/00, the vaccinee reported that he "feltsomewhat better; noise gone; hands hurt; not as stiff." He reported that physical theray "helps neck." Medications included clarithromycin 500mg twice daily, cefuroxime 500mg twice daily, sertraline 50mg daily, and alprazolam 0.5mg daily. The physician continued these medications. On 11/13/00, the vaccinee reported "light sensitivity better not florescent; feels better at night; good and bad days; marijuana helps pain neck and back in particular; anxiety continues." The diagnosis was recorded as "Lyme; anxiety" and the medication regimen was continued. The vaccinee returned to the "emerging disease" specialist on 1/8/01. At that time, the medication regiment included Celebrex 200mg twice daily, sertraline 50mg twice daily, alprazolam 0.5mg daily, cefuroxime 500mg twice daily, clarithromycin 500mg twice daily, and tramadol 50mg twice daily. The vaccinee reported "weak muscles after shower; otherwise not too bad." The medication regiment was continued. On 2/26/01, the vaccinee reported that he "hurts all over; after last visit crashed; continuous pain; hand swollen." No confusion, memory loss, tinnitus, SOB, or blurred vision were noted. The physician noted palpitations, nasal congestion, edema, decreased range of motion throughout the spine, swollen hand joints, increased paltelet count, trace protein in urine, positive Lyme IgM, and negative Lyme IgG. The physician wrote, "Possibly new infection." The diagnosis was recorded as "Lyme" and the medication regimen was continued. On 4/2/01, the physician prescribed buspizone 5mg twice daily. On 4/23/01the vaccinee reported "more depression" after alprarolam was discontinued. The physician discontinued buspirone and prescribed alprazolam 0.5mg twice daily. On 8/6/01, the vaccinee reported that he felt "better; symptoms not as frequent and not as severe; hands hurt; thoracic back pain." The vaccinee was still receiving clarithromycin 500mg twice daily and cefuroxime 500mg twice daily; these were continued On 11/12/01, white blood cell count, absolute neutrophil count, and absolute monocyte count were elevated. The vaccinee reported "joint pain and neuro no change. Duration of pain decreased. Intensity same. Depressed." The specialit discontinued clarithromycin and cefuroxime and prescribed Suprax and Zithromax. On 1/7/02, the vaccinee returned to the "emerging disease" specialist. He reported that after taking cefixime an azithromycin for two weeks, he "felt better for three weeks, went down after that. Now worse. Sharp pain. Worse when moving. Wwaking up with claws." Medications included Valtrax. No change to the medication regimen was made. On 2/18/02, the vaccinee reported that he "feels better; energy better; hands hurt; Valtrex helps energy off two days and felt it." WBC count was noted to be elevated. Medciations included valaciclovir 500mg twice daily, and tramadol. On physical examination, the physician noted edema of the hands. The diagnosis was recorded as "Lyme" and the medication regimen was continued. The most recent info, received on3/22/02, indicated that the vaccinee was feeling "better" as of 2/18/02. As of that date, he was still receiving treatment for Lyme disease. Outcome of the other reported events were not provided. The vaccinee was reportedly unable to work from June 1999 until at least 3/21/01. The follow up received on 6/20/02 states on 10/14/98 the vaccinee presented to an orthopedist for evaluation. The vaccinee completed a health assessment form at this visit and indicated he had pins and needles in his left hand, which he described as being moderate in severity and lasting for "forty-five days before 10/14/98." He indicated a modifying factor was "more work more pain." During the system review section, he indicated he had the following: good general health lately, fatigue, headaches, eye disease or injury, hearing loss or ringing, chest pain or angina pectoria, palpation, abdominal pain or heartburn, joint pain, joint stiffness or swelling, weakness of muscles or joints, muscle pain or cramps, back pain and depression. The orthopedist noted "the pt is in with his left side. He has an unusual picture. He states the arm goes numb and tingles. On examination the numbnes is in the area of hte forth and fifth fingers. He has a positive Tinel's at the cubital tunnel at the ulnar nerve and numbness along the forth and fifth fingers. He does not have any clawing but it does bother him. He does a lot of work loading and unloading trucks. He has pain in the shoulder as well with pain up the arm. He has subdeltoid tenderness on the left side with a postiive impingement test. For that I gave him a cortisone injection. The arm seems stable. X-rays of the shoulder are normal except he does have a calcific area of tendon between the acromion and humaral head. He is awakened at night with numbness in the hand recommended to see a neurologist for sort of a tremor in the eyes and he has had a history of hypertension." On 7/28/00, the vaccinee presented to a orthopedist "for re-evaluation of neck and arms symptoms with subjective weakness." The vaccinee completed a health assessment form at this visit, in which he indicated he had constant aching pain in his neck and back, which he indicatedwas a severity of 8 out of 10 had lasted for over one year. He also stated it was associated with a headache. His medical history included "arthritis/gout." During the system review section, he indicated he had the following: recent weight change, fatigue, headaches, blurred or double vision, swelling of feet, ankles or hands, joint pain, joint stiffness or swelling, weakness of muscles or joints, muscle pain or cramps, back pain, frequent or recurring headaches, lightheaded or dizzy, numbness or tingling sensation, memory loss or confusion, depression, insomnia, and Lyme disease. Examination revealed "near full cervical range of motion however he is hyperreflexia thoughout his upper and lower extremities. He has positive Hoffman's bilaterally and has three beats of clonus bilaterally. His toes are upgoing with Babinski's bilaterally. His objective motor testing appears to be 5/5 throughout. He has a recent MRI of his cervical spine which shows severe stenosis at the mid cervical down to C6-7. Cervical spondylosis and myelopathy. At this point in time the pt will likely rerquire surgical decomprression. On 8/10/00, the vaccinee's orthopedist completed an application for disability retirement. The orthopedist answered the question of "Your evaluation of applicant's ability to work at his regular occupation: Explain in what way his or her symptoms or physical findings prevent him or her from working," with the answer "The pt is not able to do any lifting." He alsoi answered the question, "Is there a possibility that he or she might improve to a degree to perform his or her regular duties?" with the answer of "Yes." On 8/29/00, the vaccinee presented to an outpatient rehabilitation facility where a physiatrist noted the pt admits to present complaint of cervical pain. The pt admits that his symptoms first began in 1998 with anxiety, depression and fatigue. He admits that he was given the Lyme vaccine x three injections over a several month period. He admits that after his last injection of the series, his symptoms were exacerbated. He also admits to symptoms of joint arthralgias, hand pain, knee pain, headaches, fatigability as well as dizziness. He also admits to memory deficit as well as confusion. He admits that he sought evaluation by a Lyme specialist and continues to follow with her. He admits that he was tested positive for Lyme antibody. He admits that also around that time in 1999, he began to experience low back pain and was treated by a chiropractor. He admits that after chiropractic treatments, he began to experienced increased confusion, photophobia and nausea. He admits that recently, he began to experience neck pain and sought treatment by his family doctor. He admits that MRI evaluation of hte cervical spine revealed herniated disc." Current medications included Biaxin, Ceftin, Zoloft, Xanax, Darvocat, and Celebrex and tramadol hydrochloride on a prn basis. The physiatrist's impression was "the pt has a history of underlying Lyme disease. Rule out neurologic manifestation. Complaint of neck pain with MRI of the cervical spine from 7/7/00 with impression of disc herniation C4-5, C6-7 with cord impingment. Diffuse disc bulging with uncinate process and facet hypertrophy causing spinal stenosis. MRI of the brain from 7/7/00 with impression of normal MRI of the brain. History of reported carpal tunnel syndrome in the past. History of reported marijuana usage.Horizonal nystagmus reported since birth. compaint of multiple joint arhtralgias. Rule out secondary to Lyme's disease. History of knee arthroscopy." On 9/13/00, the vaccinee had an EMG and the impression was "Electrodiagnostic studies rreveal no evidence of carpal tunnel syndrome, peripheral neuropathy, or cervical radiculopathy in the bilateral upper limbs. Electrodiagnostic studies reveal no evidence of active cervical radiculopathy in the bilateral upper limbs." On 10/3/00, the vaccinee presented for outpatient rehabilitation re-evaluation. the physiatrist noted "Since the last evaluation he admits that he has received outpatient physical therapy with attention to cervical posture, manual traction as well as strengthening program. He admits that he was evaluated by speech therapy an