Age: 17.0
Sex: F
Vaccine: HEPA, MNQ
Symptoms: Laboratory test normal, Lumbar puncture normal, Mental status changes, Muscular weakness, Nuclear magnetic resonance imaging brain normal
Clinical narrative: This case was reported in a literature article and described the occurrence of acquired syringomyelia in a 17-year-old female patient who received Hepatitis A vaccine. Co-suspect products included MENACTRA, typhoid vaccine and yellow fever vaccine. Concurrent medical conditions included polycystic ovarian syndrome and irritable bowel syndrome. On an unknown date, the patient received Hepatitis A vaccine at an unknown dose, MENACTRA at an unknown dose typhoid vaccine (oral) at an unknown dose and frequency and yellow fever vaccine at an unknown dose and frequency. On an unknown date, several days after receiving Hepatitis A vaccine, the patient experienced acquired syringomyelia (serious criteria hospitalization), post spinal headache, feverish, weakness in extremity, confusion, clonic movements, dystonic reaction, visual hallucinations and mental status changes. The patient was treated with diphenhydramine and lorazepam. On an unknown date, the outcome of the acquired syringomyelia, weakness in extremity, confusion, clonic movements, dystonic reaction, visual hallucinations and mental status changes were unknown and the outcome of the post spinal headache and feverish were recovered/resolved. It was unknown if the reporter considered the acquired syringomyelia, post spinal headache, feverish, weakness in extremity, confusion, clonic movements, dystonic reaction, visual hallucinations and mental status changes to be related to Hepatitis A vaccine. Additional information was provided: This case was reported in a literature article and it described the occurrence of syringohydromyelia in a 17-year-old female patient who had received an unspecified yellow fever vaccine (manufacturer unknown), MENACTRA (Sanofi Pasteur), an unspecified hepatitis A vaccine (manufacturer unknown) and unspecified typhoid vaccines (manufacturer unknown). She had no recent travel history, but had been hiking earlier in the week. Concomitant medical conditions included polycystic ovarian syndrome and irritable bowel syndrome. No further information on the patient's concurrent medical conditions, medical and family history or concomitant medication was provided. On unspecified dates, the patient received an unspecified yellow fever vaccine, followed by booster doses of MENACTRA and of an unspecified hepatitis A vaccine approximately 3 weeks later and 2 doses of an unspecified typhoid vaccine, 5 and 7 days after the booster vaccinations (dosages unknown; oral administration for the typhoid vaccine, administration routes and site unspecified for the rest of the vaccines; batch numbers not provided). On an unspecified date, approximately 18 days after the administration of the yellow fever vaccine and immediately after the administration of the 2 booster vaccines, the patient stared to feel feverish and this feeling persisted for 3 days. 8 days after receiving the boosters and the day after receiving the second dose of the typhoid vaccine, the patient complained of bilateral extremity weakness while at work. Her symptoms worsened later that day and she developed confusion and began experiencing spontaneous, clonic movements in all extremities without incontinence or post-ictal period. She was brought to the emergency department by her father where dystonic reaction was suspected and treatment that stopped the movements was administered. The following day she had a normal electroencephalogram and was seen by a paediatric neurologist who thought that a neurological aetiology was unlikely and referred her to the Infectious Diseases department. That evening she experienced clonic movements again and began to have visual hallucinations. She was admitted to a different emergency department 2 days after she had started feeling the bilateral weakness. Upon admission she was noted to have altered mental status and history of clonic movements in upper and lower extremities, but she was afebrile and had no rashes. Her mother had found 2 ticks embedded, not engorged, on the back on her knee and abdomen just before her presentation to the second emergency department. She was transferred to the paediatric intensive care unit and diagnosed with syringohydromyelia of the cervical and upper thoracic spinal cord on magnetic resonance imaging. In addition to this, she developed a postural frontal headache suspected to be post-dural puncture headache secondary to her lumbar puncture during her stay in the paediatric intensive care unit. This was a serious cases as the patient required hospitalisation. Unspecified laboratory tests and urine toxicology performed on her first presentation to the emergency department were normal according to the authors. Lumbar puncture, head computerised tomography (without contrast), as well as brain and lumbar spine magnetic resonance imaging (with and without contrast) were negative. Cervical and thoracic spine magnetic resonance imaging (with and without contrast) revealed syringohydromyelia of the cervical and upper thoracic spinal cord without associated enhancement or intraspinal lesion. Initial treatment on her first presentation to the emergency department consisted of diphenhydramine and then lorazepam 1 mg (routes unspecified). Sphenopalatine ganglion block was used to treat the headache. Outcome of the initial feverish feeling was resolution after 3 days. Outcome of the frontal headache while admitted was resolved after sphenopalatine ganglion block. Outcome of the rest of the events was unspecified at the time of reporting. The authors did not comment on any causal relationship between the vaccines and the events. The authors concluded that "therapeutic epidural blood patch is currently the standard of care for post-lumbar puncture cephalalgia with a success rate ranging from 68% - 90%. Epidural blood patches are known to be associated with negative sequelae, including subdural and epidural hematoma, needle trauma, back pain, meningitis, and a possible second dural puncture. Thus, we are advocating the use of sphenopalatine ganglion block as a first-line treatment for post-dural puncture headache. Sphenopalatine ganglion block is a noninvasive anesthetic intervention with minimal adverse effects and high efficacy. It can be performed by inserting a cotton-tipped applicator saturated with 5% water-soluble lidocaine ointment through each nares bilaterally and positioning the end of the applicator tip just superior to the middle turbinate and anterior to the pterygopalatine fossa and sphenopalatine ganglion for 10 minutes with the patient in supine position".