Sex: M
Vaccine: LYME
Symptoms: Neurological examination abnormal, Neuropathy peripheral, Nuclear magnetic resonance imaging abnormal, Nuclear magnetic resonance imaging brain normal, Pain
Clinical narrative: This case was reported by a lawyer and described the occurrence of difficulty with gait in an adult 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).  At an unspecified time after vaccination with LYMERIX, the subject experienced difficulty with gait, fatigue, pain, curling of toes, tingling of extremity, headache, motor disorder, neurological problem, balance problem, activities of daily living impaired, rheumatological symptoms, neurological impairment, cognitive impairment and autoimmune disease.  At the time of reporting the outcome of the events was unspecified.  This information was received via a Statement of Injuries.  Follow-up via medical records was received on 08 August 2008.  A neurologist exam dated 21 February 2005 indicated that the subject was under treatment for post vaccination myelitis after receiving a full dose of LYMERIX in 1999 and 2000.  After receiving 5 months of IVIG, the subject became less spastic, with increased energy and slight improvement in his gait.  Treatment with IVIG, 50 grams for 4 days, every 4 weeks for 6 months (to reevaluate at a later visit) was continued.  Electrical studies dated 07 March 2005 revealed the presence of a chronic multifocal demyelinating neuropathy.  An evaluation dated 06 April 2005 reported that the subject was started of ROCEPHIN, 2 grams every day for 30 days to be reassessed later.  Further evaluation by the neurologist on 19 April 2005 indicated that the subject had been receiving IVIG for 6 months with improvement evidenced by a decrease in spasticity and decrease in clonus.  Treatment with IVIG was continued.  Examination from 27 April 2005 indicated that after one month of treatment with ROCEPHIN, the subject had increased endurance, less pain and increased energy.  Treatment with ROCEPHIN was continued.  A neurologist evaluation dated 14 November 2005 reported a diagnosis of transverse myelitis with spastic paraparesis.  The subject suffered from gait difficulties secondary to spasticity.  Treatment included baclofen 60 mg daily.  Further electrical studies performed a year or so following studies dated 07 March 2005 revealed that there had been no change in the presence of moderately severe distal demyelinating polyneuropathy, which was now amplified on the present study in the examination of the left leg, and was ascertained to be a generalized process consistent with chronic inflammatory demyelinating polyneuropathy (CIDP).  As of 02 January 2007, the subject was diagnosed with chronic inflammatory demyelinating polyradiculoneuropathy secondary to post Lyme myelitis as evidenced by a biopsy (20 July 2005) of the muscle fibers, skin and nerve of the left calf.  An EMG performed in December 2005 supported this diagnosis as well.  As of July 2005, clinical improvement was noted as evidenced by decrease fatigue, pain, stiffness and spastic lower extremities.  Report from 22 January 2006 indicated clinical improvement with better balance and some improvement of knee flexion.  In April 2006 the subject continued to improve with neuropathy and decrease in pain.  Curling of the toes was gone and heat sensitivity.  In October 2006, the subject developed pyramidal weakness with improvement in gait for the last two months, less fatigue and improved balance.  Continues IVIG treatment.  A neurologist's evaluation dated 10 April 2008 indicated that the subject had increased sensation and a decrease in pain.  No falls were noted.  After receiving a bad batch of OCTAGAM in December 2007, the subject developed numbness on the right side of the face.  The subject had spasticity of all 4 extremities and uses a walker.  Treatment with IVIG was changed to gammagrd liquid.  In a recent evaluation dated 11 March 2008, the subject continued to be symptomatic and his left ankle epidermal nerve density obtained from a skin biopsy done that day was 3.64 (low normal 5.4 - 5.7).