Age: 68.0
Sex: M
Vaccine: LYME
Symptoms: Laboratory test abnormal
Clinical narrative: This report describes the occurrence of degenerative joint disease in a 68 year old male who was vaccinated with Lyme disease vacciner recombinant ospA (LYMErix) for prophylaxis. This report was received as part of litigation proceedings, with forwrding of medical records. The subject's medical history included Lyme disease (1992, 1994, 1998); knee pain (1990); degenerative disc disease of the lumbar and thoracic areas (190); bilateral hand pain; degenerative joint disease of the left knee, right wrist, and bilateral first and second carpometacarpal joints; left foot tendonitis (1993); traumatic tenosynovitis of the right hand (1995); heel spur; plantar fasciitis (1991); elevated rheumatoid factor; decreased platelet count; gastroesophageal reflux disease; hypercholesterolemia; hypertriglyceridemia; chronic obstructive pulmonary disease; allergic rhinitis; hypothyroidism; benign prostatic hypertrophy; prostatitis; hematuria; renal cysts; gynecomastia (1993); two episodes of paronychia (1993, 1997); and onychomycosis of toe nails. Surgical history included extensor tendon repari of the right long finger after he experienced a laceration with hyperflexion of the metacarpophalangeal joint (1995), removal of a heel spur, and tonsillectomy. Concurrent medications included Prozac, Valium, Prilosec, Zantac, Hytrin, Proscar, saw palmetto, Atacand, Lopid, and Tricor. He also received an injection of influenza virus vaccine on 10/20/99. The subject received an injection of LYMErix on 8/2/99. In a Statement of Injuries, the subject's attorney alleged that the subject "suffers from degenerative joint disease, degenerative osteoarthritis in left knee and advanced osteoarthritis of the right knee which ultimately resulted in a total knee replacement. The subject suffers from pain in both knees and thumbs and fatigue." The following info was obtained from medical records. The subject was evaluated by an orthopedic surgeon as early as 3/8/90 for left knee pain and right wrist pain. At that time, the physician noted, "some early degenerative arthritis of the medical compartment of the left knee" and "mild degenerative changes" of the right wrist. Over the next few years, the subject was periodically seen by his orthopedic surgeon for treatment of lower thoracic and upper lumbar degenerative disc disease, left knee pain, and right heel spur. On 6/10/94, the subject telephoned his orthopedic surgeon requesting indomethacin "to help his hand." On 7/21/94, the subject presented to the vaccine provider with a complaint of "painful right hand times one month." Physical examination revealed "swollen dorsum of right hand at base of fourth and third fingers." The physician's impression was "Tenosynovitis right hand-R/O gout." The physician prescribed Indocin. Rheumatoid factor and Lyme antibody screen were positive on 7/26/94. The physician prescribed doxycycline. In August 1994, it was noted the subject's hands "still bother him." The physician prescribed ColBenamid. On 9/27/99, the subject returned to his orthopedic surgeon for evaluation of his left knee. The subject stated that "if he wwalks any long distances, it bothers him. He was doing a lot of walking. By the third day he could hardly walk.  He bought a knee brace. It seemed to help somewhat. Now he finds it is starting to subside a little but he has pain on the medial side. He has occasional trouble going up and down steps. No clicking, catching, locking, buckling or giving way." Physical examination revealed, "a varus about the left knee. He hasn't noted any progression of his varus. It has been this way for quite some time. He has tenderness over the medial joint line. Meniscal provocative tests are negative. He extends fully. He flexes 125 degrees. He has no effusion. No laxity. Negative lachman and Drawer." THe physician's impression was "Degenerative arthritis." He further noted, "We discussed total knee arthroplasty. He does not think it is bad enough to warrant total knee arthroplasty and I agree." The physician administered an intra-articular injection of Depo-Medrol and Lidocaine. On 2/22/00, the subject presented again to his orthopedic surgeon. He reported that he had been playing basketball on 2/14/00 and "landed wrong on his right knee. Since then, he has had pain over the medial joint line with stiffness. His left knee is starting to act up now so both knees are hurting him." Physical examination of the left knee revealed good range of motion, no synovitis, and tenderness over the medial joint line. His right knee demonstrated an effusion with limited motion; it was aspirated for 35 cc of serious fluid. Magnetic resonance imaging of his right knee, performed on 2/22/00 was abnormal. The physician injected the right knee with local anesthetic and steroid and prescribed Vioxx. On 3/9/00, the subject reported "little response" to the steroid injection, and no relief with rofecoxib. The physician wrote that the subject "is convinced there is something mechanically wrong with his knee and I explained that he did have MRI evidence of a medial meniscus tear, but he has significant degenerative arthritis and I can't tell him for sure that the meniscal tear is the source of his problems. I talked to him about arthroplasty of his right knee with the understanding when all is said and done he still has degenerative arthritis. He is anxious to have something done." The subject underwent arthroscopy of the right knee with partial medial meniscectomy on 3/15/00. On 4/4/00, the subject again presented to his orthopedic surgeon with complaints of "increased pain and swelling, right knee. It may have been from turning over his vegetable garden. He was feeling great up until then." Physical examination revealed a mild synovitis and a small effusion. His physician counseled him on his activities. On 5/24/00, the subject returned to the orthopedic surgeon due to progressive pain in both knees. "His wife concedes that he has been more active than advised." Physical examination revealed synovitis with a small effusion on the right knee an dmild synovitis on the left knee. Good motion was maintained bilaterally. The physician injected both knees with local anesthetic and steroid and prescribed Synvisc injections. The subject received a series of three hyaluronic acid injections on 6/6/00, 6/13/00, and 6/20/00, and reportedly tolerated them well. On 6/13/00, the physician noted, "He is very upset because he has Lyme vaccine and he read in the paper this morning that it causes severe arthritis in susceptible patients (up to 30% of the population)." At the subject's request, the physician completed an application for a handicapped license plate. On 6/28/00, the physician "again explained to him that his symptoms to this point I think are due to degenerative arthritis." On 6/30/00 the subject presented to the vaccine provider with knee pain. His physicians noted, "knee pain-increased after LYMErix." On 6/30/00, rheumatoid factor was "weakly reactive." Phenotyping revealed the presence of HLA-DR4 antigen. On 7/20/00, the subject again presented with "terrible" knee pain. The physician noted, "Had Lyme vaccine, tested for HLA-DR4 with questionable autoimmune arthritis." The physician order MRIs of both kees and lab analyses, which revealed abnromalities. The subject presented his orthopedic surgeon on 8/1/00 with "problems with his right knee and increasing problems with his left knee." The physician noted, "His left knee is quite acute. His pain is anteromedial and posterior." He also noted that the subject "is still preoccupied with the possibility of an autoimmune disese from his Lyme vaccine but at this point, other than arthritis symptoms in both knees and the CMC joints of his thumbs, he has no other signs or symptoms." He was referred  to a rheumatologist to "clear the air." The orthopedic surgeon concluded, "As far as his knees are concerned, I think the only definitive treatment is total knee arthroplasty, if and when he is psychologically, if not physically, prepared for it." On 1/24/01, the subject told his urologist that he had undergone "bilateral total knees" in August 2000. The subject remained under the care of the vaccine provider until at least 3/12/02, when he reported pain in his hands. The physicians noted at that time, "DJD." Following the administration of LYMErix, the subject experienced basal cell carcinoma, an infected left toe, Bell's palsy, and a tear of the medical meniscus of the right knee. These events were not reported as adverse events due to vaccine administration, but were found during the course of reveiw of the subject's medical records. Therefore, they are not listed as adverse events. The most recent info received on 9/24/02, did not provide the outcomes of the reported events. Info received on 6/25/02 indicated that degenerative joint disease persisted as of 3/12/02. The outcome of the fatigue was not specified.