Age: 35.0
Sex: M
Vaccine: ANTH, FLU3, TYP
Symptoms: Nuclear magnetic resonance imaging brain normal, Nuclear magnetic resonance imaging normal, Osteoarthritis, Paraesthesia, Red blood cell sedimentation rate normal
Clinical narrative: On 27 April 2009 he received AVA #2 to left deltoid. He again experienced site burning and soreness. Within 6-8 hours he was awakened from sleep with diffuse muscle aches, nausea and a headache. He was able to return to sleep. Within 12 hours post vaccination (28 Apr 09) he awoke complaining of paresthesia to lateral aspect of his right knee extending anteriorly down calf to dorsum of right foot ("along L5 nerve pattern"). He described this paresthesia as pins and needles or a buzzing sensation with no weakness or loss of sensation. He had been in the gym and undergoing physical therapy (PT) for lower back pain and attributed this discomfort to his exercises. 29 April 2009 (day 2) he awoke with paresthesia to both right and left lateral lower legs (L5 distribution pattern as above R>L) down to dorsum of both feet with lower back pain (3/10). He used MOBIC for pain with minimal relief. About day 4 he denied any myalgia, headache or nausea, but he was treated with a MEDROL dose pack for persistent paresthesia with partial relief (eased but did not eliminate). May 2009 PT notes report improvement in LBP (2/10) with traction treatment and decrease in "numbness/tingling" in right lateral calf and foot; however patient stated he stopped traction because symptoms were worse. 2009 Neurological examinations were normal. Review of Sept-Oct 2008 c-spine x-rays and MRI documented C5-7 central canal stenosis and degenerative disc disease and facet arthritis. (No lumbar studies available - was in theater). Paresthesia complaints persisted unchanged (denied numbness or weakness) until 04 July 2009 when he awoke with a strong stiff neck pain that he could not stretch out. O5 July 2009 he noted first bilateral upper extremity paresthesia (numbness and tingling) along ulnar nerve-C8 distribution pattern and later perineal-perianal tingling (no bowel-bladder incontinence) with spastic feelings in feet. Neck pain and bilateral upper extremity paresthesia worsened with flexion and extension of neck (such as bending over patients intubating or doing other procedures). 09 July 2009 exam noted 2 beats clonus bilaterally with L>R UE paresthesia. Spinal surgeon suspected central HNP, provided MEDROL dose pack and medevaced him to back. Patient advised "genital" paresthesia resolved within 1 1/2 weeks after using MEDROL with marked decrease in UE/LE paresthesia. However extremity paresthesia did not fully resolve. As of 11 Aug 2009, he continues to experience moderate to severe neck > lower back pain described as a stiff annoying aching (5/10) discomfort to posterior neck region. He has infrequent paresthesia at rest, experiencing paresthesia to all four extremities mainly with lifting and stretching. His paresthesia occurs with the pain and is described as a "burning feeling" lasting 30 seconds. His SF36 identified limitations with vigorous activities (running, lifting heavy objects) and with climbing several flights of stairs, kneeling, bending or stooping due to pain (not paresthesia).