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Administered by: Unknown Purchased by: Unknown
Life Threatening? No
Write-up: Symptoms started exactly 2 months after her 2nd shot. Started with headaches, nausea, vomiting, strep throat and body aches. Continues on with non-epileptic seizures, twitches, unconsciousness, long and short term memory loss, hair loss, fatigue, joint pain and neck and back pain. Continues on after 3 1/2 months. 4/27/09 Received vaccine & PCP medical records of 8/1/08-2/3/2009. FINAL DX: encephalopathy w/memory loss. Records reveal patient experienced good general health on 8/1 when seen for sports physical. RTC 8/26 w/insect bite w/swelling, warmth & pain LUE, felt sick, nausea, HA. Tx w/antibiotics. RTC 12/18 w/vomiting, abd pain, nausea, chest pain x 1 mo, coughing, earache, migraine HA increased in frequency, sore throat, fatigue & malaise x 5 mo, excessive sleeping. Tonsils enlarged, strep test (+) & dx/tx for strep pharyngitis. RTC 1/5/09 appearing ill w/sore throat, cervical lymphadenopathy, sick stomach, nausea, vomiting, low grade fever, HA, decreased appetite, dizziness. Dx w/continued strep pharyngitis. Tx w/IM antibiotic & continued on oral antibiotics for another course. Seen in ER on 1/8/09. RTC 2/3/09 w/sore throat, sister w/strep throat. Parent reported episodes of seizure like posturing, gaze palsy, opisthotonos since 1/7/09 daily until 1/19. Had multiple ER visits. Hospitalized overnight for EEG which was WNL. No further seizure episodes but significant memory loss. Neuro-psych eval dx w/30% remaining memory. Missed a lot of school. Dx 2/3 w/pharyngitis, probably viral; encephalopathy w/memory loss, uncertain nature & cause. 5/18/09 Received hospital medical records of 1/16-1/17/2009. FINAL DX: nocturnal spasms Records reveal patient experienced muscle tension, arching back, eyes rolling back, unresponsive & dystonia nightly x 7-10 days lasting 15 min to 2 hr. School performance had been affected since mid-Dec when episodes had started. Admitted for 24-hr video EEG which was WNL. Neuro exam WNL. Referred to Psych. 5/20/09 ED records received multiple DOS 1/7/09 to 1/12 FINAL DIAGNOSIS: Syncope, seizure, acute vomiting, cephalgia and neck stiffness Post vaccination: nausea, vomiting, body aches, twitching, unresponsive at home, headache, neck stiff. Dizziness, numbness, tingling in hands and feet, crying. Hyperventilation with carpal pedal spasms. Myoclonic tremors.
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