Age: 68.0
Sex: F
Vaccine: LYME, LYME, LYME
Symptoms: Affect lability, CSF test abnormal, Depressed level of consciousness, Dysuria, Gastrointestinal disorder
Clinical narrative: On 4/20/99, the pt received her 1st injection of Lymerix. Approximately ten days later, the pt experienced "extreme pain in her shoulders" which over the next 3 days began radiating down her left arm to the site of the injection. On May 1999 the pt collapsed and was paralyzed. She was hospitalized in an intensive care unit. Pt was transferred to a rehabilitation center where she spent 6 months. She was diagnosed with transverse myelitis. Treated with extensive and intensive physical, occupation, and rehabilitative therapies. She has been confined to a wheelchair and unable to walk. Pt claims she was in excellent health, completely independent prior to vax. She had numerous bites form the ticks which cause Lyme disease. The follow-up received on 02/25/2002 states that review of medical records indicated that she had a history of Lyme disease. She was allergic to sulfa and had osteoarthritis in both knees. She underwent arthroscopic right medical maniscectomy in 1988 and had moderate intermittent pain until she underwent total knee arthroplasty on 03/31/2000. Surgical history also included tonsillectomy, concurrent medications included ibuprofen, tramecol, and propranoiol. Medical records indicated that she collapse, unable to walk. Medical records from her orthopedic surgeon indicated that the pt requested total knee replacement on 02/29/200, eventhough she had not been medically cleared for the surgery, because pre-existing osteoarthritis of her right knee was the thing that's holding her back from recovering from transverse myelitis. She underwent right total knee arthroplasty on 03/31/2000. The most recent info was received on 02/25/2002. Medical records indicated that as of 06/18/2001, the pt could walk with a hemi-cane. She still required supervision and occasional assistance. The follow-up states that the medical history also included urinary tract infection, unspecified and mitral valve. During a physical therapy session on 05/11/00, the physical therapist noted that the pt "still has gross weakness due to transverse evelitis. Pt is making progress in her mobility. The follow up states one of the vaccinee's physicians submitted a report directly to VAERS (ID 122248). The following info was obtained from medical records. On 5/3/99, the pt presented to the local ER. She was "referred for sudden onset of left-sided weakness that morning. Starting three days ago, she developed pain across her shoulders radiating into the left deltid region. This pain continued on a fluctuating basis over the next two days, but she remained active, doing quite a bit of walking, even yesterday. Last night, she developed increased pain in her shosulder while in bed, and some tendency of her legs to jump during sleep. By 5am, this morning, she noted weakness of the arm and then rapidly of the left leg. There was also some numbness to the left arm. On examination in the ER, a neurolgoist had examined her and she was admitted to the ICU. At that time, the results of an MRI and CT scanof the head and spinal tap were "essentially normal." She was carefully evaluated and her respirations were monitored. Her respirations were never compromised, however, she had to be fed by the nurse and family members. The pt had denied any trauma, but had a Lyme disease vaccine a few days ago. According to the neurologist's evaluation, "there is increased tone in th elimbs with flexor spasms in the legs and left arm. The left arm and leg are 0/5 throughout. The right arm showed biceps 3/5, deltoid 0/5, brachioadialis 3/5, decreased right fine finger movements. The right leg iliopsome 2/5, hamstrings 3/5, tibialis anterior 3/5 and gastroce 4+/5. There is s decreased pin sensation in the right leg compared to the left. Touch and joint position sense in the legs is intact. There is inconsistent decreased sensation in the left arm, especially to touch. Sensation across the shoulders is diminished to pin. Flexes revealed: knees are 3+, ankles are 3+, triceps are 3+, and absent at the biceps and brachioradialis, all bilaterally. There are bilateral babinski signs. Coordination and gait "count not be treated." The impression: "the pt has an acute cervical spinal cord syndrome, which has, unfortunately rapidly progressed to severe quadriparesis. There is some evidence of a C4-C5 process by the pattern of weakness and distribution of pain. This could be compressive, such as an osteophyte from cervical spinal stenosis. This could be inflammatory form a transverse myelitis. She recently received the Lyme disease vaccine, which is relatively new." Recommendation: "MRI of the cervical spine. Decadron and Pepcid were given IV." 5/4/99, schocardiogram showed: "there was mitral annular calcification and all valves appeared to be within normal limits in anatomy and motion." For the next couple of days her movements did not improve. 5/5/99 chest x-ray revealed: "cardiomegaly, no evidence of active pulmonary disease. There is no significant interval change." On the third day, 'there seemed to be some slight improvement in her right upper extrremity and also she was moving the fingers on the left hand" which were described as "subtle movements." Results from unspecified cultures and the spinal tap were inconclusive. 5/7/99, a chest x-ray showed "plaque atelectasis of the right lung base." On 5/7/99, rehabilitation was consulted with the chief complaint of "the need for interdisciplinary rehabilitation secondary to spastic quadriparesis brought on by transverse myalitis." It was noted that during her hospitalization, she "underwent extensive testing inclusive of MRI of cervical and lumbar spine, spinal tap and various additional tests (not specified). From these tests, two possible diagnoses included: spinal infarct at the C5 level and the more probable one being a Lyme vaccine induced transverse myelitis with resulting spastic quadripareiss. She continued quadriparesis but intact sensation, with an indwelling Foley and loss of bowel control. She was admitted to the rehabilitation unit. Medications upon transport included propanolol, Pepcid, and beclofen. On musculoskeletal examination noted: "the pt was able to abduct right upper extremity to only 30 degree from midline. Deltoid and triceps strength was graded at 2/5. Biceps strength was3/5, hand grasp was 5/5. Left upper extremity: almost complete flaccidity is noted with the exception of beginning of proximal tone with the ability to shoulder shrug. All other tested muscle groups in the upper extremity were 0/5. Lower extremities: the pt's quad strength in right lower extremity grade at 1+/5. Hip flexor strength 1/5. Dorsiflexionand plantar flexion was 1/5. There is evidenc eof spasticity with attempted movement of right lower extremity. Left lower extremity: left lower extremity is almost completely flaccid with some minor spasticity noted. Sitting balance is poor. On neurological examination: DTR's are slightly hyperreflexive in the upper extremities; hyporeflexive in the lower extremities. There is a positive transverse myelitis, enurogenic bowel and bladder, and mitral valve prolapse." Rehabilitation goals and plan: "work closely with her for what would be a for at least a four to six week period in helping first to just improve her sitting balance and transfers with a sliding board. Hopefully, also she regains greater muscle tone and strength we will be albe to ultimately progress in the point of short distance ambulation with any devices or bracing as needed for ambulation with a walker. Work on bladder regimen by returning independent urination and work on bowel program by using Senokot at hours of sleep and glycerin suppository in the morning. On 5/7/99, the pt was discharged from the hospital to the rehabilitation facility. On 6/25/99, the rehabilitation team indicated that she still needed intermittent catheterizations. She was able to use a sliding board and tried a motorized wheel chair. They noted, "attitude good, but in denial." On 7/8/99, rehabilitation team noted that pt was voiding, but low-volumes. She was prescribed Urecholine, Fosamax, and Ensure for nutritional supplementation. On 7/21/99, the pt was evaluated by the rehabilitation team following encephalitis. Her function mobility/endurance evaluation reported: "she is current ambulating 40 feet with bilateral knee splints and moderate assistance. She required minimum to moderate assistance for transfers and maximum assistance for sit to stand as well as moderate assistance for bed mobility." Her self care skills indicated that she required "minimal assistance to no assistance for lower and upper body care. Her continuing goals noted: "increase strength and endurance as well as ambulation status, transfer to sub-acute unit on 7/30/02 to continue her rehabilitation as long as it was necessary until she obtained a morre satisfactory mobility status for herself." The pt was transferred from the acute section of the rehabilitation facility to the sub-acute section on 7/29/99. In the discharge summary, the physician reported the diagnosis of "spastic quadriparesis secondary to transverse myelitis, neurogenic bowel and bladder, history of mitral valve prolapse and histroy of cardiac arrhythmia." The physician stated "when she first was admitted herre, she was quadriparetic in all four extremities with just some minimal hand movement in the right upper extremity. She had completely neurogenic bowel and bladder and had an indwelling Foley catheter. We are pleased to say that she actually made very nice functional gains by the time she left us and then went to our rehabilitation subacute unit for further treatment. She ultimately got to the point where she was using a sliding board transfer to and from the wheelchair with supervision to minimum assist of one. She had good return of upper extremity strength and function, and was self-feeding and self-dressing her upper extremieits upon discharge with bracing and MDFOS on the lower extremity, she ultimately went from completely wheelchair dependent to being able to stand for short periods, to being able to walk distances of about 40-50 feet with maximum assist to one for trunk and spinal stabilization." She was starting to experience good return of sensation of urine and bowel. She had one vasovagal response after an enema. Her bowel routine consisted of two Senokol tablets during hours of sleep and then just digital stimulation three days a week. The enema had been; however, the pt was "frightened to use this after she had a drop on blood pressure on 7/19/99." She remained stable with the "exception of urinary tract infection which she had been treated with antibiotics." Unspecified lab evaluation and doppler studies were performed and were all within normal limits. On 12/7/99, the physical therapist wrote, "(The subject) has received 14 physical therapy sessions since 10/28/99...Patient ambulates with rolling walker times 150-200 feet and requires CG [contact guard] to close close supervision. [The subject] has made some gains in bed mobility, transfer adn ambulation distance. She also has demonstrated inconsistent gains in LE (lower extemity) strength. She continued to demonstrate difficulty with sit to stand." On 1/10/00, her rehabiliation physician evaluated the subject. He wrote "she remains quadriparetic at the C5-6 level secondary to transverse myelitis. She reports no new neurologic symptoms and her spastic quadriparesis persists, but with gradually improving strength and endurance. Her trunk and left extremeties are most severly involved, with relatively good preservation in the right leg. her chief complaint today is of pain in her right knee...She feels this is markedly limiting  her ambulation, but with minimal assistance to stand, she could ambulate 200 feet from me today with a rolling walker, requiring only close supervision. She required minmal assistance to stand. There is mild atrophy in the left leg, none in the right, or in the arms. She has a distincly greater increase in tone in the left leg, with 3-beat ankle clonus (no clonus on the right)." Phonophoresis with .05% fluocinonide (Lidex) gel was prescribed. On 4/14/01, the pt had follow up visit with rehabilitation physician in regards to the possible benefits of additional physical therapy. The physician noted that her "surgery went well with marked reducation in pain and instability in her right knee following knee arthroplasty. This had allowed her to be much more active over the past year." She is now an independent household ambulator and had had parallel bars installed in her living room to permit her to practice daily. Her wheel chair was used for "long distance travel in the community," however, she could ambulte out of doors with a rolling walker. The ? suggesting deterioration in her other joints. He noted "she now manages completely independently except for a few hours of help from an aide in the evening when she is more tired and less safe." General health was noted as "excellent" and her only medications are a Bufferin and occasioanl Aleve for joint pains, Baclofen for her hypertenicity and Indural for her mtiral valve prolapse. She had fully control of her bowel and bladder, but with some bladder urgency, no dysuria or other symptoms suggesting urinary tract infection. Upon re-examination, her sitting balance, standing balance and ability to maneuver had improved. Motor power in the right leg was now in the good to good minus range and she can effectively lock both knees, even though motor power in the left leg was a grade weaker and motor power that was overwhelmed by increased tone The pt continued to have left ankle clonus (two beats) and generally increased deep tendon reflexes, but increased tone does not interfere significantly with function in the right leg or upper extremities. THe physician indicated that "while her posture was somewhat bent over, her gait was safe. her increased tone in the left leg made dorsiflexion difficult and she used a number of compensatory mechanisms, including hip hiking and circumduction. Recommendation: "course of physical therapy, this time adding therapeutic pool to dry land therapy in order to reduce her tone. In June, a trial with tapering and discontinuing Baclofen. On 5/29/01, the subject had a follow-up visit with her rehabilitation physician "to evaluate her progress with a new course of physical therapy instituted to take functional advantage of her ongoing slow neurological gains. [The subject] was in high spirits and was eager to demostrate her ability to rise independently from her wheelchair, and to initiate walking with a quadruped cane held in her stronger right hand. She begun to learn to flex her left knee during swing phase, but still exhibits a slight amount of left toe drag; there is decidely less tendency to left knee buckling than before, due both to improved ambulation technique and to strengthening of her left quadriceps. Her balance and coordination now are excellent, and her functionally nomral sensory awareness contributes to provididng an inherently safe gait, which I strongly feel can be further inmproved upon with continued therapy in the weeks ahead." On 6/25/02 the internal medicine progress notes indicated that for the past 2-3 years the pt had right shoulder pain and at night she had burnign sensation at the scapular. At this visit, the pt was continuing with bladder problems and was taking Ditropan. Upon physical examination, there was increased fluid in the right shoulder at the scapular area. The internist's impression was "The underlying problem of the right shoulder was due to pt ambulation without using the walker. Plan: ortho, urologist and Bextra." On 11/9/01, a Lyme serology info sheet was filled out by the pt. She also reported that she had not been diagnosed with Lyme disease. She indicated that she had experienced reactions which she felt were a result of the Lyme vaccine. She described these reactions as pain at the injection site which lasted for three days and joint pains for three days of both shoulders. A variety of serologies for Lyme disease were performed. The lab's overall interpretation was "no evidence of seroactivity beyond that expected from the Lyme vaccine." The most recent info was received on 8/6/02. Medical records indicated that, as of 6/18/01, the pt could walk with a hemi-cane. She still required supervision and occasional assistance. Info was received from the pt on 2/23/01. She stated, "some mobility returned but I am in a wheelchair most of the time." The pt considers the transverse myelitis to be "resulting from the LYMErix vaccine."