Age: 40.0
Sex: M
Vaccine: MMR, TTOX, MMR, TTOX
Symptoms: Arthralgia, Myalgia, Pain, Paraesthesia
Clinical narrative: Information has been received from a health professional concerning a 40 year old male with no known allergies who on 1/15/02 was vaccinated with 1 dose of MMRII (lot 639378/0591L). Concomitant therapy that same day included 1 dose of DT, Nasonex, PRN and loratadine (Claritin) PRN. It was noted that the pt did not have any chronic medications. On 2/1/02, the pt experienced myalgia, arthralgia and paresthesia in the arms and later, in the legs, as well. It was noted that the pt had tried Tylenol but that did not offer much relief. It was noted that the time of the report, 3/18/02, the pt was a little better, the last few days. It was unknown if the pt sought medical attention. Additional info has been requested. A 15-day follow up report received on 6/4/2003 adds: Initial info has been received from a health professional on a 40 year old male pt with chronic allergic rhinitis, "allergy symptoms", an allergy to ketorolac tromethamine (TORADOL) (resulted in vomiting) and a history of a kidney stone, who had never been hospitalized. Additional info was received regarding a case in litigation. On 01/15/2002 at approx 10:30, the pt was vaccinated with the first dose of measles virus vaccine live (+) mumps virus vaccine live (+) rubella virus vaccine live (second generation) in the right deltoid (Lot #639378/0591L). Concomitant therapy that same day included the fifth dose of diphtheria toxoid/tetanus toxoid (DT VAX) (lot #U0516AA) in the left deltoid, mometasone furoate (NASONEX) PRN, loratoadine (CLARITIN) PRN, and a dose of tuberculin purified protein derivative (lot #C0867AB). It was noted that the pt did not have any chronic medications. On 02/01/2002 the pt experienced myalgia, arthralgia and paresthesia in both arms, that spread to both of the legs (also reported as upper bilateral extremity pain that spread to the lower extremities). The pt's experience was further described as "achiness in his arms, then some numbness". Over the next few weeks he developed similar symptoms in his legs, calves and ankles. He had joint pain in his hands and ankles. It was noted that the pt had tried acetaminophen (TYLENOL) but that did not offer much relief. On 02/05/2002, he was evaluated by a physician's assistant who documented that 4 days previously, the pt began to have some bilateral "right" upper extremity "achy" pain involving both forearms and also the right deltoid. Theh pt did not complain of weakness. He was noted to have full active range of motion of both upper extremities and strong biceps and triceps strength. There was no swelling, inflammation or tenderness of the extremities upon palpation. A CPK was normal at 64. It was noted that the pt's "handout" regarding diphtheria toxoid/tetanus toxoid contained a comment about "deep aching upper extremity pain", so he presented for evaluation. At that time, the upper arm pain etiology was documented to be "unclear". It was noted that the pt would inform the physician's office if the symptoms "just improve with time". That same day, he also reported that he had some urinary difficulty a couple of days prior. He was noted to have taken doxazosin mesylate (CARDURA) and was having no prostate problems at the time of evaluation. On 03/08/2002, he was evaluated by a chiropractor for diagnosis and treatment. The chiropractor noted pain and swelling in the right sternoclavicular area. Further documentation included "functional left short leg with Derifield's positive for pelvic involvement. Muscle spasm left quadratus lumborum. Increased tension with fixation left suboccipital". CMT was performed to facilitate segments at left S1, C1, D12, sacrum, right hip and right sternoclavicular. Following CMT leg length was noted to be even and the pt tolerated the treatment well. "Multiple areas of subluxation treated with chiropractic adjustments" was documented. On 03/12/2002 he returned to the chiropractor. It was noted that his neck stiffness improved, but the pt had intermittent stiffness in the jaws. The left lower extremity was in external rotation with functional left short leg. He had soreness at the sternocostal left first rib. Again, CMT was performed to facilitate segments at C1, D1, D7, D8, occiput, left hip and tibia. Following CMT, there was a reduction in external rotation and functional leg length was even. On 03/15/2002, he was again evaluated by the chiropractor. It was documented that there was improvement with tightness in the neck and back, but the pt still experienced intermittent numbness and tingling along the left side of his body. Reduction in areas of joint dysfunction compared with prior visits and leg length even was documented. There was "significant" external rotation of the left lower extremity, which improve after CMT, but is not symmetrical. The pt decided to follow-up prn. On 03/18/2002, he followed-up with the physician's assistant and indicated that the pains had spread to his lower extremities. He also had some paresthesias. He had a "little" discomfort in his ankles and calves. The pt stated that over the prior 3 days, the symptoms seemed to be improving and that he did not have any "really physical findings to be noted". It was documented that the pt had spoken to his sister who is a nurse and that she told him these reactions can sometimes be seen after a measles virus vaccine live (+) mumps virus vaccine live (+) rubella virus vaccine live (second generation) adverse reactions. The pt reported that his chiropractor "suspected possible adverse reaction to vaccines" and that the physician's assistant researched measles virus vaccine live (+) mumps virus vaccine live (+) rubella virus vaccine live (second generation) adverse reactions and also suspected a possible vaccine adverse reaction. "Adverse reaction to the M-M-R" was documented in the medical record. On 03/21/2002, he returned for evaluation by the physician's assistant. The pt reported that his joint symptoms were primarily in the ankles, hands, wrists and fingers. He thought that over the previous week, the symptoms had been improving. He had no swelling of his joints. No abnormalities were noted involving the wrist and finger joints. He had good range of motion of all his fingers. The pt wished to be treated with "sample" non-steroidals rather than prescription of diclofenac. He was given rofecoxib (MSD) 12.5 mg one po QD. He was instructed to follow-up in about a month. The pt reported that the symptoms lasted for three months and subsided by approx 04/10/2002 (previously reported as 04/22/2002). It was noted that the pt had a previous dose of mumps in 1975, measles in 1964, and rubella in 1971. The pt had received 4 previous doses of diphtheria toxoid/tetanus toxoid with the last dose given in 1978. Urinary difficulty, neck stiffness, jaw stiffness, multiple areas of subluxation, soreness at the sternocostal left first rib and functional left short leg were considered to be incidental findings. No further info is available. Follow up information has been received from the patient. The patient reported that he has not had any more new symtpoms, and he "did suffer physically and also with some mental anguish." He stated that "I just know my own body and I've only had those reactions in my body (reported previously) after receiving the vaccines." No further information is available.