Age: 76.0
Sex: M
Vaccine: LYME
Symptoms: Hypoaesthesia, Lumbar radiculopathy, Lumbar spinal stenosis, Muscle spasms, Muscular weakness
Clinical narrative: This case was reported via medical records forwarded by a lawyer and described the occurrence of arthritis aggravated in a 77-year-old male subject who was vaccinated LYMERIX, (GlaxoSmithKline). The reporting attorney did not specify the events that were attributed to LYMERIX. The following information was received on 08 April 2009 via medical records. Prior to vaccination with LYMERIX, the subject experienced cervical spondylosis (asymptomatic), right shoulder achiness/numbness, right sided facial numbness, and arthritis. The subject received his first and second doses of LYMERIX on 19 April 1999 and 17 May 1999 respectively. A note on 17 May 1999 indicated that the subject had "no side effects after either the first or second injection". On 20 April 1999, the subject presented with groin pain and right upper leg pain noted with activity, subsequently radiating along the anterior aspect of the knee and resulting in difficulty walking. He also noted start up pain after prolonged sitting. Lumbar spine x-rays showed "a physiological amount of arthritis throughout the lumbar area", with moderate right hip osteoarthritis. He was diagnosed with osteoarthritis of the right hip with associated synovitis, and underwent aspiration of the hip joint. On 21 September 1999, the subject presented with pain on his right side that was "completely alleviated" if he was not active. He reported that pain was nonexistent if he took four to six aspirin per day. Pain was primarily along his right trochanter and groin. In December 1999, he presented with knee pain and degenerative changes of the knee and hip, treated with ADVIL and glucosamine chondroitin. In early 2000, the subject developed back problems. On 10 May 2000 he was diagnosed with ischial bursitis treated with DECADRON, XYLOCAINE, NAPROXYN and TYLENOL No. 3. He underwent a laminectomy in June 2000 due to severe lumbar spinal stenosis. The subject presented on 02 November 2000 for a complaint of right leg pain (onset approximately August 2000) with sciatic pain that reportedly limited his daily activities. The evaluating neurologist stated that it was unclear whether the leg pain was arthritic in nature or due to nerve compression. On 30 November 2000, right leg pain and severe spinal stenosis were completely resolved. On 12 December 2000, the subject was evaluated by a neurologist for complaints of achiness in the legs, particular in the thighs, since undergoing the laminectomy. He was noted to be significant for spinal stenosis and arthritis. Impression included proximal muscle weakness particularly hip flexion bilaterally, with cramping. The neurologist indicate the possibility that symptoms were a late effect of the laminectomy. He was seen for neurophysiologic study on 04 January 2001 to further investigate achiness in legs, with nerve conduction studies/electromyography findings "probably related to a late or chronic lumbar polyradiculopathy involving segments L4/5 and to a lesser extent S1". At that time, he complained of numbness in the hands suspected to be related to carpal tunnel "although a C5/6 radiculopathy needs to be differentiated". ROBAXIN was advised for muscle cramping of legs. On 30 January 2001, neurophysiologic studies were performed for further investigation of hand numbness, and findings were consistent with a bilateral median neuropathy and right ulnar neuropathy. Treatment included CELEBREX. On 12 March 2001, the subject complained of bilateral thigh pain, with persisting leg achiness in May 2001. It was noted that "ROBAXIN and VIOXX have a limited effect". On 13 July 2001, the subject described spasm in both legs and thigh muscles, and it was noted that "it certainly appears to me that his problem is related to his back; the pain comes and goes depending on position". He presented for follow up on 07 August 2001 and 29 August 2001 with recurrence of bilateral leg pain, and it was noted that the subject had what "may be symptomatic, iatrogenic, L4/5 spondylolisthesis". Notes also described "unrelenting pain and weakness of the thighs", and it was recommended that hip replacement be delayed. Treatment included VIOXX. On 04 October 2001, assessment included advanced arthritis of the right hip. On 20 November 2001, he underwent a right hip replacement procedure (total right hip revision/right internal fixation of femur". He was discharged on VICODIN, temazepam, and ferrous sulfate for postoperative anemia. The subject was hospitalized on 07 December 2001 after sustaining a fall at home. He was diagnosed with a fracture of the right femur, and required surgery. Bone densitometry findings revealed hip osteoporosis. He was transferred for rehabilitation from 12 December 2001 to 19 December 2001 for ongoing therapy and medical care following his hip repair. Treatment included physical therapy. On 19 March 2002, the subject was reportedly "finally feeling better" without the severe pain he had been experiencing in the past. Back, hip, and arm were healed. On 20 August 2002, he was evaluated for shaking and chills at night, "more consistent with a summer virus" and treated with TEQUIN. On 20 November 2003, he was seen for a three week history of itching without rash, and was treated with ATARAX, Doxepin, and Sarna lotion. Itching persisted in December 2003. In February 2004, he was noted to have borderline macrocytic anemia. At the time of reporting the outcome of the events was unspecified.