Age: 58.0
Sex: M
Vaccine: LYME
Symptoms: Rotator cuff syndrome, Surgery, Synovitis, Walking aid user, Wheelchair user
Clinical narrative: This case was reported by a lawyer and described the occurrence of rheumatological symptoms 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. On an unspecified date the subject received unspecified dose of LYMERIX (unknown). According to the statement of injuries, at an unspecified time after vaccination with LYMERIX the subject experienced "pain, swelling, and stiffness in his joints and muscles? headaches, flu-like symptoms, possible memory loss, and decreased activities of daily life". The statement of injuries also alleged that the subject experienced "rheumatologic, neurologic, and/or cognitive impairment of an autoimmune, immune-mediated, or other mechanism all caused by vaccination with LYMERIX including but not limited to those set forth above." At the time of reporting the outcome of the events was unspecified. Follow-up information in the form of medical records was received 08 September 2008. A Lyme serology information sheet completed by the subject on an unspecified date reported that following the 2nd LYMERIX, he has suffered from chronic joint pain in both knees, wrists, shoulders, ankles, feet, hands, fingers and the spine. Other complaints were swelling of the hands, feet, fingers and knees and chronic fatigue. Lyme serology testing dated 19 March 2002 was negative. Follow up information was received on 19 November 2008 via medical records. A progress note dated 15 February 2001 indicated that the subject had a history of possible Lyme disease with joint pain since September 2000. The subject was under the care of an orthopedist from 13 September 2000 to 06 May 2003 for problems including shoulder pain, left shoulder strain, full-thickness rotator cuff tear, synovial swelling of the wrists and fingers, adhesive capulitis (left shoulder), and musculoskeletal pain. On 06 December 2000, the orthopedist noted that "since I last saw him, he has been diagnosed with Lyme vaccine reaction. He has diffuse joint aching". Physical therapy was unsuccessful in relieving symptoms, and he underwent an arthroscopic capsular release of the left shoulder on 21 May 2001, and on 11 September 2002 was noted to have good motion on elevation and external rotation. On 06 May 2003, and on 11 September 2002 was noted to have good motion on elevation and external rotation. On 06 May 2003, it was noted that the subject attributed musculoskeleta problems to Lyme disease. On 25 February 2005, the subject underwent a below the right knee amputation due to complications of diabetes and circulatory issues; he had an artificial limb which he did not use. He utilized a walker and a wheelchair. The subject was treated by a rheumatologist from as early as November 2003 to as recently as May 2008 for complaints associated with his rheumatoid arthritis, as well as synovitis of the wrist and osteoarthritic changes of the left knee (known torn cartilage of left knee). The subject was evaluated by his rheumatologist on 21 May 2008, at which time he was status-post rectal cancer surgery (January 2007) and was in a wheelchair. He reported waxing and waning arthritis symptoms that were weather-related. It was also reported that the subject had known osteoporosis. Wheelchair design resulted in repeated ankle trauma. On 14 July 2008, diagnostic findings were consistent with a combination of both rheumatoid and osteoarthritis of each hand and wrist. During the course of his treatment, the subject's medications included prednisolone, MOBIC, methotrexate, ENBREL, and PERCOCET.