22 Oct 2009 - SM received his 2nd TWINRIX vaccine. He does not recall any unusual or prolonged local reactions or systemic symptoms following vaccine receipt. He specifically denied any symptoms of upper respiratory or gastrointestinal symptoms during weeks prior to or on the day of vaccine receipt. 10 Nov 2009 - SM received H1N1 vaccine (IM). Following administration of the H1N1 vaccine, SM does not recall any unusual reactions at the vaccination site. He denies being sick at the time he received this vaccine. He specifically denies upper respiratory or gastrointestinal symptoms during weeks prior to or on day of vaccine receipt. 12 Nov 2009 - SM sought evaluation for lightheadedness, double vision, problems with equilibrium, and numbness in his extremities. He was treated with IVF and placed on quarters x 24 hours. 13 Nov 2009 - SM returned to the clinic for evaluation of double vision, problems with balance, headache and tingling sensation in his extremities and across his upper chest. He had a normal CT of his head, On exam, his DTRs were diminished and SM had an ataxic gait. He was evaluated by Optometry, who assessed his diplopia as EOM palsy/6th nerve with other neurological symptoms not of ocular origin. SM was also referred to Internal Medicine, who after examination consulted with Neurology. Neurology felt SM had Miller-Fisher Syndrome and should recover spontaneously. 20 Nov 2009 - SM was evaluated by Neurology. It was noted that SM reported about a 2 week history of URI symptoms, with ongoing headache and sinus pressure. At time of evaluation, reported symptoms had stabilized, but SM continued to have diplopia, tingling in his feet and fingers and difficulty walking. Neurology Assessment: Trial of opthalmoparesis, areflexia, ataxia is consistent with Miller Fisher syndrome, particularly in the absence of evidence of brain lesion on imaging. The onset 2 days after that H1N1 vaccine would be relatively quick but cannot rule out this as an etiology. His prior upper respiratory symptoms indicate likely viral infection at the time of the vaccine which would indicate a possible multi-factorial systemic Immune response as etiology...patient was admitted to Hospital between 13 and 30 Nov 2009. While admitted, patient received supportive care including physical and occupational therapy was initiated. He did not receive IVIG. His work-up noted low thiamin and B12 levels. Patient received one dose of IM B-12 and oral supplementation was initiated. SM was also treated with ZITHROMAX for sinusitis with symptoms resolving. A persistent fever was noted, with negative blood cultures. This was felt to be discharge. Asymptomatic, persistent, microscopic hematuria was also noted, with normal renal CT. Following discharge from hospital, patient was placed on 30 days convalescent leave. 4 Feb 2010 - patient evaluated by Neurology and continued improvement of symptoms was noted with patient reporting that his walking was back to 100% normal. Patient's vision "Is mainly single, but with being tired or looking in certain directions, will have double vision, maybe 15-20% of the day will have horizontal diplopia over the last week or so." He was cleared to return to basic training. Neurology Assessment: Miller-Fisher Syndrome - Near complete resolution of symptoms. This is expected to be a monophasic illness with complete recovery. At this point he should be to return to training. I would not restrict his physical activity and his present condition does not fail retention standards. I recommend he return to training. There is no foreseeable problem which should not interfere with his ability to complete AIT, or continue on in his expected field in the military.