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Administered by: Military Purchased by: Military
Life Threatening? No
Write-up: 21 y/o female seen in ER 13 May with C/O it hand & lt. foot numbness approximately 1 month post GARDASIL vaccine. She also C/O of nausea, vomiting and diarrhea. A heat CT demonstrated bilateral basal ganglion infarcts and a MRI showed with similar results with no acute process. She was admitted 20 May with left hemiballsmus. On 22 May her mental status declined. She received many doses of HALDOL and ATIVAN for agitation and was intubated on 28 May. She was transferred to medical center 28 may for w/u for encephalitis and has since become comatose. Symptoms: Nausea w/vomiting, Diarrhea, Nausea w/o vomiting, Numbness. 7/11/08 Reviewed hospital medical records for 6/11-6/23/2008. FINAL DX: aseptic meningo-encephalitis; choreoathetosis r/t meningo-encephalitis; paroxysmal autonomic instability w/dystonia; e. coli UTI. Records reveal pt transferred from military hospital. Military deployment 1-3/2008. On leave 5/2008 developed n/v/d, abd pain & bifrontal HA which continued to worsen. Sought medical help but no dx given. Developed left side weakness, flaccidity & several falls. Found 5/12 unable to ambulate & incontinent of urine. Taken to ER where MRI revealed possible basalganglia infarct. To ICU where subsequent MRIs were WNL. Ventilated & remains in persistent vegetative state. LPs done. PICC , trach & PEG tubes. Intermittently febrile, labile BP, asystole x2. Tx in multiple hospitals w/multiple meds including steroids, IVIG, antibiotics & antivirals. 12/11/08 Reviewed additional medical records of 5/08-7/08. FINAL DX: Records reveal patient experienced nausea/vomiting/diarrhea, dizziness & HA, left hand/foot numbness x 4-5 days. Seen in ER on 5/13 where labs were WNL but CT of brain revealed lacunar infarcts, bilateral basal ganglia & cavum verge. Numbness continued & developed involuntary jerking of LEs & difficulty walking. Admitted to MICU 6/08 w/encephalitis. Tx w/IVIG & steroids. Transferred to higher level of care & then to inpatient rehab program.
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