Age: 13.0
Sex: F
Vaccine: HPV4
Symptoms: Red cell distribution width normal, Tremor, Vaccination complication
Clinical narrative: Information has been received from a Nurse Practitioner concerning a 12 years old female who on an unspecified date was vaccinated with a dose of GARDASIL (therapy route and lot # not provided). Two hours after the patient received GARDASIL, she experienced numbness and tingling. Two weeks later, the patient experienced "weakness". The patient sought unspecified medical attention. Patient's present status was not specified by reporter. Follow up information has been received from medical records via the nurse practitioner concerning the patient who was 14 years (previously reported as 12 years old). The patient was vaccinated with the first dose of GARDASIL (lot # 666929/0331Z) in the left deltoid on 04-AUG-2010. Concomitant therapy included VYVANSE. The patient experienced muscle twitching and numbness with pain in legs and hands (onset date reported as 06-AUG-2010). The numbness increased daily until she was taken to emergency room (10-AUG-2010). The patient also had constant sense of dyspnea and could not get enough air in. On 19-Aug-2010(at 13:21) the patient was seen in the emergency department with chief complaint of leg numbness. Patient stated that it was hard for her to breathe and her legs "fell asleep" and keep on twitching and her hands "fell asleep" and got a tingling sensation. She denied pain, fever, vomiting and headaches. History of present illness: the patient presented with leg numbness bilateral for 1 week. The onset was gradual. The symptoms were numb/twitches. She had GARDASIL 2 weeks ago. Now with leg twitching and tingling in both hands, also with sensation of difficulty breathing. Furthermore, the patient/family denied muscle weakness, fevers. The patient stated exacerbating factors that occur were none. Radiating symptoms included no radiations. Upon visit, her temperature (oral) was 36.2, pulse 91, respirations 16, BP 100/66, pulse oximetry 100% ra, no pain, lung sounds clear. Physical exam had no abnormal findings. Patient had normal reflexes bilaterally. Pediatric neurology had no concern for Guillain-Barre Syndrome (GBS) or other acute neurologic disease. No symptoms of objective findings that were life or limb threatening. The patient was medically screened and stable for disposition from the emergency department. Lab tests revealed: pulse oximetry normal, erythrocyte sedimentation rate (ESR) 7, blood chemistry was within normal  limits. Diagnoses were leg numbness and paresthesia. On 19-AUG-2010 ( at 17:18) the patient was discharged home in good condition. She was instructed to return to emergency department immediately if the symptoms worsen or new symptoms develop. In October 2010, the patient was reported as "904" recovery, and on unspecified date, the patient had recovered. On 19-OCT-2010 the patient visited a doctor of pediatric neurology clinic. According to the doctor, the patient's past medical history included: born at term by C-section, had tonsils out around age 3 due to hypertrophy and resultant obstruction with snoring. She has had no other major accidents, illnesses or injuries. She was diagnosed of attention deficit disorder, and for that she takes VYVANSE 40 mg daily. Higher doses had caused anorexia. She did not have allergies to medications. Retrospect of the patient's experiences: Within about an hour of the shot she complained of local pain at injection site with numbness that was radiating down to her arm, and then into her left hand. Then she started to have muscle twitches all over. Then she felt as if she were having intermittent numbness in her legs, feet and hands as they were falling asleep. The worst thing she felt was that she had a constant sense of dyspnea, as if she could not get enough air in. This got to the point were the patient was taken out of diving, by her diving coach, because he felt that she just did not seem right. She also had some vague whole body shaking episodes which did not clearly sound like convulsions. She went to emergency department (on 19-AUG-2010), she was noted to have intact reflexes, and was thought to be dehydrated. There  was no clear concern for Guillain-Barre, at that point. At her worst she said she was about 40% of who she typically was, now she said she was about 90% of who she typically is. Her main complaints now were occasional twitching, numbness that could occur anywhere, and only occasional shortness of breath. She was markedly improved in her symptomatology overall. Exam showed: the patient had no clear stigmata of neurological disease. S1 and S2 were present, and a regular rate without murmur. Lungs clear to auscultation. Abdomen soft without evidence of organomegaly. Extremities without clubbing or edema. She was awake and alert with a good fund of knowledge. Funduscopy was easy with clear disk margins noted bilaterally. Smell was not tested, and the remainder of her cranial nerves were intact. Motor testing revealed 5/5 strength throughout. Tone and bulk were normal. Sensation was intact to temperature, vibration and light touch. Coordination revealed normal finger-nose-finger and heel-to-shin maneuvers. Gait was normal on casual, bipedal, tandem, heel and toe walking. Reflexes were 2/4 throughout. Toes were bilaterally downgoing. Assessment/plan by the doctor: "This is a 14-year-old, left-handed, young lady with an adverse reaction to a vaccine, or an adverse reaction that is reasonably attributed to a vaccine. At this point, I am not sure there is anything to do. It may be that this is "a near miss Guillain-Barre", as she did not have a spinal tap demonstrating cytoalbumenic dissociation there would be no way to know for sure. With preserved reflexes, in the ER, when she was seen I am not sure I would have done the test either". The doctor recommended watchful waiting at this point and recommended that she not get the next two HPV vaccines. No further information is available.