Age: 22.0
Sex: M
Vaccine: ANTH, SMALL, TYP, ANTH, SMALL, TYP, ANTH, SMALL, TYP
Symptoms: Blood creatine phosphokinase normal, CSF culture negative, CSF glucose normal, CSF protein normal, CSF white blood cell count positive
Clinical narrative: This case was received on 10 May 2010 via QScan search on the VAERS database, under reference number 380746. A 22 year old male patient received the following vaccines on 15 January 2010: ACAM2000 (lot number VV04003A); TYPHIM Vi (lot number B1026) and BIOTHRAX (Emergent Biosolutions, lot number FAV204). Two days after vaccination the patient experienced a slight fever. On day 3 and day 4, the patient developed nausea, dizziness, shivering and swollen lymph nodes. The patient was seen in the emergency room for these symptoms. On day 5, the patient was seen again in clinic for the same symptoms and the addition of slight fever. The patient was instructed to remain in his room. On day 6, the patient developed uncontrollable muscle convulsions in the core of the body. He was seen in the Emergency Room again, prescribed VALIUM and BENADRYL and instructed to remain in room. The VALIUM controlled the tremors. The tremors return when the patient stops taking the VALIUM. The following events were noted in the report but details were not provided: somatoform disorder, headache, myalgia, nausea, musculoskeletal pain, upper respiratory tract infection, tonsillar hypertrophy, and injection site warmth and erythema. Blood work, spinal tap, MRI, CAT scan, and urinalysis were performed. The following results were noted in the report but details were not provided. A culture of the CSF was negative. An electroencephalogram was reported as normal. A streptococcus test was negative. The spinal cord MRI was reported as abnormal. A CAT scan was normal. A drug screen was negative. Note: There may be a discrepancy between the event date field and the onset date information in the free text narrative field in the data reported. Latency has been calculated using the event date. Follow-up received on 12 May 2010 from the Centers for Disease Control. The report included the entire text narrative from the VAERS database. The patient initially presented on day 5 with sore throat, fever (99-102 degrees Fahrenheit), waves of dizziness, and sore left axillary lymph nodes lasting for 3 days. The patient self-treated with ibuprofen. The patient was diagnosed with upper respiratory tract infection and sent home with orders to take acetaminophen and PHENERGAN. Two days later, the patient was seen again with complaints of involuntary muscle jerking and twitching of the upper body which which had a gradual onset over the past week. The smallpox vaccination site (left shoulder) was red and warm. The patient underwent a lumbar puncture (reportedly clear); was treated with IV fluids and diphenhydramine HCL; and was prescribed BENADRYL and ATIVAN. The diagnosis was muscle shaking. The patient was stable and then discharged with plans for follow up with his healthcare provider and an MRI of the brain (date not provided). The MRI showed nonspecific region of T2 hyperintensity in the deep right parietal lobe white matter, most likely reflecting reactive astrogliosis. The patient had a EEG on 24 February 2010 which was performed awake and drowsy xl. A neurological assessment (date not provided) noted recent subacute onset of asynchronous distractible and non-stereotyped movements. The patient was examined and movements were not consistent with a dyskinetic disorder. Tourette syndrome was unlikely. The diagnosis was most likely psychogenic movement disorder. Patient was evaluated in behavioral medicine clinic and the assessment noted there was no obvious psychological factors that would significantly cause or maintain current symptoms of motor tremors. The recommendation was to continue neurological workup. On a follow-up visit (date not provided), the patient was noted to appear uncomfortable with constant tremors of upper half of the body. There was no psychological symptoms and the patient was treated with gabapentin. The patient was referred to an allergy clinic to rule out allergic reaction to vaccination. The assessment from the allergy clinic (24 February 2010) was the symptoms were not related to vaccine, was in agreement with previous neurological assessment of conversion disorder, and that the patient would benefit from intensive psychiatry evaluation. On 05 March 2010, the patient presented to a clinic for treatment of tremors and muscle pain. It was recommended the patient be seen and admitted for 24 hour video at a movement disorder clinic and for the symptoms of myalgia and myositis. The patient was encouraged to try biofeedback to lessen the involuntary movements. The following diagnostic and laboratory results were noted: CT brain, normal; CPK; normal; LP, normal (glucose-55, protein-25, RBC-2, WBC-3); CSF culture, no growth; latex agglutinations, negative; urine drug screen, negative; rapid strep, negative; MRI spine, abnormal (1-2 prominence of the ependymal canal at the C5 level); MRI brain, abnormal (nonspecific region of T2 hyperintensity in the deep right parietal lobe white matter; this most likely reflects reactive astrogliosis). An EEG showed enhanced beta activity consistent with patient history of benzodiazepine use along with frequent movement artifact and tachycardia appropriate to the rate of movement, but otherwise a normal EEG for age. Frequent movements were observed without evidence of EEG correlate.