Age: 62.0
Sex: M
Vaccine: VARZOS
Symptoms: Blood immunoglobulin G normal, Blood magnesium normal, Blood phosphorus normal, Borrelia test negative, C-reactive protein
Clinical narrative: This 62 year old retired patient reported receiving typhoid, influenza and Tdap vaccinations (receipt could not be verified) approximately 2 weeks prior to receipt of ZOSTAVAX vaccination in July 2013. He denied any adverse reactions following any of these vaccinations. However review of his medical records lists Tdap was given on 8/11/2012, influenza on 10/10/2011 and ZOSTAVAX on 6/17/2013. There were no typhoid immunizations in available immunization records. [Note: Immunization records from 1970 to 2001 (retired in 2001) were not available.] He presented to medical on 8/20/2013 with a one week history of a sharp burning radiating pain to his lower back-spinal area and right hip pain that worsened daily with numbness first to sole of left foot then up left leg, then right leg and groin. He denied any loss of mobility or strength. He was sent to the emergency room where an MRI was reported to be "normal" and he was sent home on ULTRAM. On 8/23/2013 he stopped his ULTRAM due to nausea and vomiting reporting onset of several small fluid filled red itchy patches to his right hip (size of EKG patch). This rash lasted 2 days before resolving spontaneously. On 8/24/2013 his pain, nausea and vomiting worsened and he had cold sweats. He returned to the ER 8/25/2013 complaining of no bowel movement in 3 days with about 10 episodes of grossly bloody bowel movements with clots x 12 hours. He was admitted for GI evaluation (complete colonoscopy, labs, et al). GI providers also documented complaints of constant pain without radiation to right flank/right lower back and lower extremity numbness x 2 weeks but their exam had no "subjective complaints of musculoskeletal weakness, joint discomfort or function and no extremity rashes, strength in lower extremities was 5/5 and symmetric with sensation intact bilaterally". On 8/27/2013 prior to discharge he reported being unable to stand up and had no control of his legs. Neurology evaluation 8/27-30/2013 documented a subacute progressive spinal cord syndrome of sensory loss to arms/legs and perineum, and weakness to hip flexors, problems up-going toe on right, and bowel bladder dysfunction. Neurology documented his wife advised them on 8/30/2013 that her husband (patient) was given a "DTaP and varicella vaccination about one week prior to onset of symptoms". Providers diagnosed with myelopathy-acute transverse myelitis (T3-L1) following MRI spine and lumbar puncture, and administered "pulsed high dose glucocorticosteroids". He advised he was able to sit with some return of bowel-bladder function about 8 hours after first dose IV steroid but his numbness and back pain persisted. He was released on 8/30/2013 with continued improvement (full strength arms/legs, hypersensitivity to feet/this, walks with walker...) on titrating prednisone (60 mg x 1 week, 40 mg x 1 week, and 20 mg x 6 weeks), gabapentin for pain/numbness and ongoing physical therapy. On 10/7/2013 this retired patient and his wife presented to facility for initial evaluation for causality assessment of reported vaccines and onset of Transverse Myelitis. He reported marked improvements in symptoms over past month with increased sensation to knees but still numbness in tibia and feet. He walks with a cane and can walk 2 miles around neighborhood. He is driving again. His urinary and bowel continence is improving. On 11/19/2013, they questions why vaccines remain undocumented and how the facility can correct this. He continues to follow up with neurologist. He currently walks with a cane and continues to complain of hypersensitivity to feet/lower extremities and shooting electrical pains. He has no bowel/bladder dysfunction and has full use of upper extremities.